Massage Consultation Form

Massage Consultation Form
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (including country code)*
Please enter a valid phone number.
Email*
example@example.com
Sex*

FemaleMale
Date of Birth*

DayMonthYear
Date
Number of Children (If Applicable)
Age Group*

Under 2020-3030-4040-5050-6060+
Current Activity Levels*

ActiveSedentary
Last visit to Doctor*

DayMonthYear
Date
Date of last period (If Applicable)

MonthDayYear
Date
Contraindications (Please tick where appropriate) Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.

PregnancyCardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)HaemophiliaAny condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, CoachMedical oedemaOsteoporosisArthritisNervous/Psychotic conditionsEpilepsyRecent operationsDiabetesAsthmaAny dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)Bells PalsyTrapped/Pinched nerve (e.g. sciatica)Inflamed nerveCancerPostural deformitiesDysfunctions of the nervous systems (e.g. cerebral palsy/sroke/ Multiple sclerosisKidney infectionsWhiplashSlipped discUndiagnosed painWhen taking prescribed medicationAcute rheumatism
Contraindications that restrict treatment (Please tick where appropriate)

FeverContagious or infectious diseaseUnder the influence of recreational drugs and/or alcoholDiarrhea or vomitingSkin diseasesUndiagnosed lumps or swellingsLocalised SwellingInflammationVaricose veinsPregnancy (abdomen)CutsBruisesAbraisonsScar tissues (2 years for major operation and 6 months for a small scar)SunburnHormonal implantsAbdomen (first few days of menstruation depending how the client feels)HaematomaHemiaRecent fractures (minimum 3 months)Cervical spondylitisGastric ulcersAfter a heavy meal
Written permission required by Specialist*

YesNo
Personal Information

Please tick or answer where appropriate
Muscular/skeletal problems

BackAches/painsStiff jointsHeadaches
Digestive Problems

ConstipationBloatingLiver/Gall bladderStomach
Circulation

HeartBlood pressureFluid retentionTired LegsVaricose VeinsCelluliteKidney problemsCold hands and feet
Gynaecological

Irregular periodsPMTMenopauseHRTPillCoil
Nervous System

MigraineTensionStressDepression
Immune System

Prone to infectionsSore throatsColdsChestSinuses
List any Antibiotics/Medication taken
List any Herbal remedies taken
Ability to relax*

GoodModeratePoor
Sleep quality*

GoodPoor
Average hours sleep per night*
Do you see natural daylight in your workplace?*

YesNo
How many hours a day do you work at a computer?*
Do you eat regular meals?*

YesNo
Do you eat in a hurry?*

YesNoSometimes

How many portions of each of these items does your diet contain each day?*

	Qty
Fresh Vegetables
Fresh Fruit
Meat
Fish
Dairy
Sweet Things
Added salt
Added sugar

How many units of these drinks do you consume per day*

	Qty
Tea
Coffee
Fruit Juice
Water
Soft Drinks

Do you suffer from any of the following

Food allergiesOver eatingBinge eatingBulimiaAnorexia
Please list any food allergies
Do you smoke? If So how many cigarettes do you smoke daily
Do you drink? If so how many units of alcohol do you consume per week?
Do you exercise? If so how many times per week?
What is your skin type?*

DryOilyCombinationSensitiveDehydrated
Do you suffer or have you suffered from

DermatitisAcneEczemaPsoriasisAllergiesHay FeverAsthmaSkin Cancer
Stress levels at home (10 being highest)*
Stress levels at work (10 being highest)*
Right or Left Handed*

RightLeft
Massage Details
Do you wish to have a Swedish Massage or a Sports massage?*

Swedish Massage (if yes, please answer N/A to the questions in this section)Sports Massage (if yes, please answer all the questions in this section)
What sports/activities do you participate in?*
What is your main sport/activity*
How long have you been doing this?*
At what level do you patriciate?*

RecreationalClubRegional/County LevelNationalInternationalOther
How often do you play/train per week?*
What is your preferred position/discipline/distance within your sport?*
Please list any injuries sustained whilst participating in your sport or activity?*
Emergency Contact Details
Emergency Contact *

First NameLast Name
Relationship to you*
Emergency Phone Number*
Please enter a valid phone number.
Disclaimer Form

Please read the following and tick the appropriate box, by ticking the box you are confirming you are in full agreement with the statements contents.
Client Information*

I confirm that I have understood the treatment that I am going to receive. I also confirm that I am willing to proceed without confirmation from my own G.P or Consultant.I confirm that I have understood the treatment and given my medical history I would prefer to consult with my GP or Consultant prior to receiving the treatment.
You should note that if the therapist is unable to explain to you the contraindications or is unsure of anything that may apply to a specific condition then they should not treat you without asking you to consult with your GP or Consultant. It is your responsibility and not that of the therapist to consult your GP or Consultant.*

I hereby indemnify the therapist (Vina Bhabhani) against any adverse reaction sustained as a result of the treatment.
Client Full Name*
Signature*

Clear
Signature
Date

DayMonthYear
Date
Hour Minutes
Should be Empty:

Massage Consultation Form

Personal Information

Massage Details

Emergency Contact Details

Disclaimer Form