Pre Massage - Health Questionnaire

1
Full Name
First Name
Last Name
2
Date of Birth
Date
Day
Month
Year
3
OccupationOr previous occupation if retired
4
Have You Ever Had:
Please Select
Heamophilia
Heart Attack
Osteoprosis
Surgery (In The Last 2 Years)
Thrombosis
5
Please Give More Information:
6
Do You Currently Have:
Please Select
Herniated Disc
Acute (very recent) Injuries
Acute (very recent)Trapped or Pinched Nerve (ex. Sciatica)
Allergies
Back Injury
Bone Fracture (in the last 2 years)
Cancer
Cardiovascular Conditions
Cervical Spondylitis
Circulatory Problems
Contagious or Infectious Disease
Diabetes
Epilepsy
Fever
Fibromyalgia
Gastric Ulcer
Hernia
Headaches
High Blood Pressure
Kidney Infections
Medical Oedema
Neck Injury
Nervous Disorders
Osteoarthritis
Osteoporosis
Pelvic Inflammatory Disease
Phlebitis
Pregnancy
Rheumatoid Arthritis
Skin Cancer
Skin Conditions
Urinary System Disorders
Varicose Veins
7
Please Give More Information:
8
Current Medications
9
Previous Accidents or Injuries
(i.e. Childhood Illness, Hospitalization, Illness, Operations, Falls, Accidents)
10
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