Massage Form First Name Last Name D.O.B Height Weight What is the main reason for this session? From the list below, please note which of these conditions are relevant to you. Muscle or joint pain or stiffness Shortness of breath, asthma depression, anxiety bruise easily Numbness or tingling High/low blood pressure Stroke/heart attack Cancer Broken bones Varicose veins Headaches, migraines sensitive to touch/pressure Swelling Dizziness, ringing in ears epilepsy, seizures arthritis Gas, bloating, constipation scoliosis Osteoporosis, degenerative spine Neurological (e.g. MS, Parkinson’s, chronic pain) memory loss Digestive conditions (eg crohn's) Diabetes, endocrine/thyroid conditions kidney disease PTSD Colostomy bag Blood clots Pitted oedema Current infection Sensitive to hot or cold Current injuries None Other Other - Please describe How would you describe you stress levels? What are causes of stress for you? Have you received professional massage/bodywork before? Do you need assistance getting on and off the table? Can you lie on your front and back? What kind of pressure do you prefer? Light Medium Firm Is there anything else you'd like to mention? Please give your consent for your details provided in this form, plus your medical information (if relevant) to be shared with your therapists. This information will support them to give you the best treatment possible. Please select an option below Yes I consent No, I do not consent submit
