Massage Consultation Form
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (including country code)
*
Please enter a valid phone number.
Format: (00) 00000000000.
Email
*
example@example.com
Sex
*
Female
Male
Date of Birth
*
-
Day
-
Month
Year
Date
Number of Children (If Applicable)
Age Group
*
Under 20
20-30
30-40
40-50
50-60
60+
Current Activity Levels
*
Active
Sedentary
Last visit to Doctor
*
-
Day
-
Month
Year
Date
Date of last period (If Applicable)
-
Month
-
Day
Year
Date
Contraindications (Please tick where appropriate) Never treat unless the injury has been diagnosed and treatment has been recommended by a medical practitioner.
Pregnancy
Cardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)
Haemophilia
Any condition already being treated by a GP or another health professional, e.g. Physiotherapist, Osteopath, Chiropractor, Coach
Medical oedema
Osteoporosis
Arthritis
Nervous/Psychotic conditions
Epilepsy
Recent operations
Diabetes
Asthma
Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)
Bells Palsy
Trapped/Pinched nerve (e.g. sciatica)
Inflamed nerve
Cancer
Postural deformities
Dysfunctions of the nervous systems (e.g. cerebral palsy/sroke/ Multiple sclerosis
Kidney infections
Whiplash
Slipped disc
Undiagnosed pain
When taking prescribed medication
Acute rheumatism
Contraindications that restrict treatment (Please tick where appropriate)
Fever
Contagious or infectious disease
Under the influence of recreational drugs and/or alcohol
Diarrhea or vomiting
Skin diseases
Undiagnosed lumps or swellings
Localised Swelling
Inflammation
Varicose veins
Pregnancy (abdomen)
Cuts
Bruises
Abraisons
Scar tissues (2 years for major operation and 6 months for a small scar)
Sunburn
Hormonal implants
Abdomen (first few days of menstruation depending how the client feels)
Haematoma
Hemia
Recent fractures (minimum 3 months)
Cervical spondylitis
Gastric ulcers
After a heavy meal
Written permission required by Specialist
*
Yes
No
Personal Information
Please tick or answer where appropriate
Muscular/skeletal problems
Back
Aches/pains
Stiff joints
Headaches
Digestive Problems
Constipation
Bloating
Liver/Gall bladder
Stomach
Circulation
Heart
Blood pressure
Fluid retention
Tired Legs
Varicose Veins
Cellulite
Kidney problems
Cold hands and feet
Gynaecological
Irregular periods
PMT
Menopause
HRT
Pill
Coil
Nervous System
Migraine
Tension
Stress
Depression
Immune System
Prone to infections
Sore throats
Colds
Chest
Sinuses
List any Antibiotics/Medication taken
List any Herbal remedies taken
Ability to relax
*
Good
Moderate
Poor
Sleep quality
*
Good
Poor
Average hours sleep per night
*
Do you see natural daylight in your workplace?
*
Yes
No
How many hours a day do you work at a computer?
*
Do you eat regular meals?
*
Yes
No
Do you eat in a hurry?
*
Yes
No
Sometimes
How many portions of each of these items does your diet contain each day?
*
Rows
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
*
Rows
Qty
Tea
Coffee
Fruit Juice
Water
Soft Drinks
Do you suffer from any of the following
Food allergies
Over eating
Binge eating
Bulimia
Anorexia
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?
*
Dry
Oily
Combination
Sensitive
Dehydrated
Do you suffer or have you suffered from
Dermatitis
Acne
Eczema
Psoriasis
Allergies
Hay Fever
Asthma
Skin Cancer
Stress levels at home (10 being highest)
*
1
2
3
4
5
6
7
8
9
10
Stress levels at work (10 being highest)
*
1
2
3
4
5
6
7
8
9
10
Right or Left Handed
*
Right
Left
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?
*
Recreational
Club
Regional/County Level
National
International
Other
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 Name
Last Name
Relationship to you
*
Emergency Phone Number
*
Please enter a valid phone number.
Format: (00) 00000000000.
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
*
Signature
Date
-
Day
-
Month
Year
Date
Hour Minutes
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