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Consultation Form

Get In Touch

Consultation Form


PRINT OFF AND COMPLETE CONSULTATION FORM PRIOR TO TREATMENT


On-Site-Massage & Therapies  


Client name:…………………………………………………………………………………………………

Profession:…………………………………………………………………………………………………….

Tel no:……………………………………..

Email:……………………………………………………………………………………………………………

Address:………………………………………………………………………………………………………..


Personal Details (circle which applies)

Age group ☐ under 20 ☐ 20-30 ☐ 40-50 ☐ 50-60 ☐ 60+

Lifestyle ☐ active ☐ sedentary

Contraindications requiring medical permission Check the box if you have any of the following:

☐ pregnancy

☐ cardiovascular (thrombosis/phlebitis/hypertension)

☐ haemophilia

☐ osteoporosis

☐ arthritis

☐ nervous/psychotic conditions

☐ epilepsy

☐ multiple sclerosis

☐ parkinson’s disease

☐ diabetes

☐ cancer

☐ acute rheumatism

☐ slipped/prolapsed disc

☐ bell’s palsy

☐ trapped nerve (sciatica)

☐ postural deformities

☐ kidney infection


Clients Signature ………………………………………………….. date …………………………………………….

Therapists Signature ……………………………………………… date ……………………………………………..


Personal Information

Muscular/skeletal problems ☐ back ☐ aches/pains ☐ stiff joints ☐ headaches

………………………………………………………………………………………………………………………………………………..

Digestive problems ☐ constipation ☐ bloating ☐ stomach ☐ liver/gall bladder

.............................................................................................

Circulation ☐ heart ☐ blood pressure ☐ varicose veins ☐ fluid retention ☐

………………………………………………………………………………………………………………………………………………

Gynaecological ☐ Irregular ☐ PMT ☐ Menopause ☐ HRT ☐ Pill ☐ Coil

Nervous system ☐ Migraine ☐ Tension ☐ Stress ☐ Depression

Immune system ☐ Prone to infections ☐ Sore throats ☐ Colds ☐ Chest ☐ Sinuses

Regular Antibiotic/Medication taken? ☐ yes ☐ No If yes, which ones (Include Herbal Remedies)

……………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………

Ability to Relax ☐ Good ☐ Moderate ☐ Poor

Sleep Pattern ☐ Good ☐ Poor ☐ Average No of Hours ……..

Food Allergies ☐ Yes ☐ No If yes what food ……………………………………………………………..

Do you smoke ☐ Yes ☐ No If yes how many a day ………………………………………………………

Do you drink alcohol ☐ Yes ☐ No If yes how many units per day …………………………………………….

Do you exercise ☐ None ☐ Occasional ☐ Regular – please state which:

………………………………………………………………………………………………………………………………………………

Stress levels 1 – 10 (10 being the highest) Work ………… Home …………….

How many units/glasses of these drinks do you drink daily? Fruit Juice ……. Coffee ……

Water ……… Tea ………. Other ………………………………………………………………………………………

How many portions of each of these items does your diet contain per day?

Fresh Fruit …......................  Fresh Vegetables ….....................  Protein ….. ……………………………………………………………….