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Client Consultation

Strictly Confidential

Are you over the age of 21?
Yes
No

Health

Please consider the following and describe any health conditions or symptoms you may have:

If you answer yes please give information below and discuss with your therapist prior to your massage.

Skin condition: e.g. psoriasis, eczema, dermatitis, acne, rosacea, allergies…
Yes
No
Skeletal/Muscular system: e.g. back, neck, feet, leg, hip, arthritis, rheumatism, stiff joints or anything else.
Yes
No
Circulation: e.g. stroke, restless legs, varicose vein, blood pressure, cold hands/feet or anything else.
Yes
No
Respiratory system: e.g. asthma, bronchitis, sinus, cough, breathlessness or anything else.
Yes
No
Urinary: e.g. cystitis, candida, swollen ankles, kidney infection, night frequency, incontinence
Yes
No
Nervous system: e.g. epilepsy, mood swings, anxiety, depression – mild or severe, on medication or anything else.
Yes
No
Digestive system: e.g. constipation/diarrhoea, flatulence/bloating, IBS, indigestion, gall stones, haemorrhoids, abdominal pain, overeat/under-eat or anything else.
Yes
No
Endocrine: e.g. diabetes, hormonal imbalance, thyroid disorders, MS/ME, loss sex drive, lethargy, osteoporosis, adrenal disorders or anything else.
Yes
No
Reproductive: e.g. reproductive disorders including breasts disorders or anything else.
Yes
No
Are you pregnant?
Yes
No
Are you currently taking any medication?
Yes
No
Are you currently being treated by a doctor, other health care professional or any other therapist?
Yes
No

Additional Information

Do you have any allergies?
Yes
No
Do you use an inhaler or epi-pen? If yes please state which type you use:
Yes
No
Any recent operations, illness or injury? (last 12 months)
Yes
No
Any serious operations, illness or injury.
Yes
No

CLIENT DISCLAIMER  I confirm that it is my responsibility and not that of the therapist to consult with my GP before the treatment if I have any health conditions or concerns. I am willing to proceed without my GP consent or consultation prior to receiving treatment. All information given in this form is true to the best of my knowledge. I hereby indemnify the therapist against any adverse reactions sustained as a result of the treatment.

Do you agree?
I agree
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