Questionnaire for massage

Book your appointment with us and fill in the online consultation form to be ready for your session.

Full Name

Date of Birth

Email Address

Contact Number

Have you ever had massage therapy before?YesNo

Do you have allergic reactions to oils, lotions, ointments, liniments or other substances put on your skin?YesNo

Are you currently under medical supervision?YesNo

If yes, please specify

Are you currently pregnant?YesNo

If Yes, Due Date?

Have you been sick (cold, flu, fever, etc) in the last 7 days?YesNo

If yes, please specify

Are you taking medication?YesNo

If yes, please specify

Are you wearing/have any of the following?ContactsDenturesPace MakerPortsHearing Aids

What are your goals for today’s massage?

AccidentCurrentlyHistory

Accident Date

WhilpashCurrentlyHistory

Whiplash Date

HeadachesCurrentlyHistory

Heart Attack / ProblemsCurrentlyHistory

StrokeCurrentlyHistory

Stroke Date

High | Low Blood PresureCurrentlyHistory

DiabetesCurrentlyHistory

EdemaCurrentlyHistory

Skin DisordersCurrentlyHistory

Abdominal PainCurrentlyHistory

Digestive DisordersCurrentlyHistory

ScoliosisCurrentlyHistory

SprainsCurrentlyHistory

Sprains Date

Broken BonesCurrentlyHistory

Broken Bones Date

Disk ProblemsCurrentlyHistory

Prosthetics | Artificial JointsCurrentlyHistory

Arthritis | Join AcheCurrentlyHistory

FibromyalgiaCurrentlyHistory

HepatitisCurrentlyHistory

HIVCurrentlyHistory

CancerCurrentlyHistory

Please Specify

Breast AugmentationCurrentlyHistory

Please Specify

SurgeryCurrentlyHistory

Please Specify

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Please select the places you are feeling discomfort add legs:C-1C-7T-5T-12L-5SARCUMHAMSTRINGSGLUTESCALVESQUADRICEPSTIBIALIS ANTERIORSOLEUSFOOTDELTOIDTRICEPS BRACHIIBICEPS BRACHIIBRACHIORADIALISNECKHEAD

How did you hear about us?

*The usage of silicon cups is required in specific kinds of treatment. Please let us know if you are happy to have them on your session (no extra charge) *yes I’m happy to used them on my treatmentno I don’t want them to include on my treatment==no I don’t want them to include&nbsp

Cupping Therapy

Confirmation *I understand that massage is not in replacement for medical care and that no diagnosis will be made.

Confirmation *I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on changes in my physical health. With this in mind, I agree that the massage therapist cannot be held liable for any problems that might arise as a result of my massage sessions.

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