Skip to the content
Homepage
Shop Packages
View Packages
Giftcard
Relaxing Massage
Therapy Massage
Mini Massages
Children Massage
Facial Treatments
Contact Us
➔ Facial Form
➔ Massage Form
➔ Packages Form
Cancellation policy
Homepage
Shop Packages
View Packages
Giftcard
Relaxing Massage
Therapy Massage
Mini Massages
Children Massage
Facial Treatments
Contact Us
➔ Facial Form
➔ Massage Form
➔ Packages Form
Cancellation policy
Questionnaire for massage
1
1
https://naturoteaspa.co.uk/wp-content/plugins/nex-forms
https://naturoteaspa.co.uk/wp-admin/admin-ajax.php
https://naturoteaspa.co.uk/massage-form
1
fadeIn
fadeOut
Full Name
Date of Birth
Email Address
Contact Number
Have you ever had massage therapy before?
Yes
No
Do you have allergic reactions to oils, lotions, ointments, liniments or other substances put on your skin?
Yes
No
Are you currently under medical supervision?
Yes
No
If yes, please specify
Are you currently pregnant?
Yes
No
If Yes, Due Date?
Have you been sick (cold, flu, fever, etc) in the last 7 days?
Yes
No
If yes, please specify
Are you taking medication?
Yes
No
If yes, please specify
Are you wearing/have any of the following?
Contacts
Dentures
Pace Maker
Ports
Hearing Aids
What are your goals for today’s massage?
Accident
Currently
History
Accident Date
Whilpash
Currently
History
Whiplash Date
Headaches
Currently
History
Heart Attack / Problems
Currently
History
Stroke
Currently
History
Stroke Date
High | Low Blood Presure
Currently
History
Diabetes
Currently
History
Edema
Currently
History
Skin Disorders
Currently
History
Abdominal Pain
Currently
History
Digestive Disorders
Currently
History
Scoliosis
Currently
History
Sprains
Currently
History
Sprains Date
Broken Bones
Currently
History
Broken Bones Date
Disk Problems
Currently
History
Prosthetics | Artificial Joints
Currently
History
Arthritis | Join Ache
Currently
History
Fibromyalgia
Currently
History
Hepatitis
Currently
History
HIV
Currently
History
Cancer
Currently
History
Please Specify
Breast Augmentation
Currently
History
Please Specify
Surgery
Currently
History
Please Specify
HTML
Please select the places you are feeling discomfort add legs:
C-1
C-7
T-5
T-12
L-5
SARCUM
HAMSTRINGS
GLUTES
CALVES
QUADRICEPS
TIBIALIS ANTERIOR
SOLEUS
FOOT
DELTOID
TRICEPS BRACHII
BICEPS BRACHII
BRACHIORADIALIS
NECK
HEAD
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 treatment
no I don’t want them to include on my treatment==no I don’t want them to include 
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.
Submit Form
0
0
Your Cart
Your cart is empty
Return to Shop
