Treatment date

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What treatment are you booked in for?

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Have you had massage therapy before?

Yes

No

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If yes, when and what treatment?

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About You ^*

First Name ^*

Last Name ^*

Date of Birth ^*

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Your Address ^*

House Number or Name ^*

Street or Road Name ^*

Town or City ^*

County

Post Code ^*

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Contact Number ^*

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Email ^*

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Emergency Contact ^*

First Name ^*

Last Name ^*

Phone Number

Relationship To You

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To ensure I can provide you with the most suitable treatment. I just need a bit of information about your general health and medical background.

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Do you bruise easily

Yes

No

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Are you on any medication? ^*

Yes

No

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If Yes, Please list below.

/

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Do you have any areas of concern? (i.e. left shoulder, right knee etc) ^*

Yes

No

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If Yes, Please list below.

/

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Do you have any allergies? (i.e. oils, lotions, nuts, fruits, scents, brand type?)

Yes

No

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If Yes, Please list them below.

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Are you Pregnant?

Yes

No

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If Yes, Please can you note down the due date, and/or any complications with current or previous pregnancy

/

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Are you currently under any medical supervision or receiving medical treatment?

Yes

No

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If Yes, Please provide details below.

/

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Have you had any recent medical procedures or surgeries?

Yes

No

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If Yes, Please describe type of procedure/surgery. When did you have it?

/

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What is your occupation?

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Please indicate how often you exercise 👇

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Consent

By proceeding to the next page and signing. You confirm that all the information provided is accurate to the best of your knowledge, and that you consent to receive massage therapy treatment. Please inform me (your therapist) of any changes in your health status before your treatment

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Please sign here. ^*

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Thank you for completing this questionnaire. I will be in contact with you to discuss and answer any questions before your treatment. I look forward to our appointment!

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Youform

Welcome back! Loading your previous answers...

Thank you for your booking your treatment with me!

To ensure I can provide you with the most suitable treatment. I just need a bit of information about your general health and medical background.

Consent

Thank you for completing this questionnaire. I will be in contact with you to discuss and answer any questions before your treatment. I look forward to our appointment!

Thank you! 🙌