Consultation Form | Massage training

First name

Last name

Address

Phone

Birthday

Day

Month

Year

Next of Kin Name & Tel No

Doctors Name, Address & Tel No

Could you be pregnant/are you trying for a baby?

Do you have any children? If so, how many and what are their ages?

Have you had any recent illnesses, injuries or operations in the past 6 months?

Are you under the care of a GP/health professional?

Are you on any medication? Please list

General Health – Good/Poor/Average

Stress Levels – Low/Medium/High

Do you have any of the following? High/low blood pressure, Heart disorder/disease, Swellings, HIV/Aids/Hep B or C, Recent haemorrhage, Asthma, Diabetes, Metal implants, Pacemaker, Epilepsy, Skin Disorder or disease - if so, please explain

Do you have any of the following? Eczema, Arthritis, Rheumatism, Undiagnosed Lumps, Cancer, Allergies, Sensitive Skin, Varicose Veins, Cellulitis, Hormonal Problems, Fractures, Sprain, Severe Bruising, Thrombosis, Embolism - if so, please explain

Do you have any of the following? Kidney Disorder, Cuts/Abrasions, Recent Scar Tissue, Mental Health Issues, Digestive Issues , Circulatory Disorder, Muscle spasm, Scalp Infection, Migraine, Dysfunction of Nervous System - if so, please explain

Do you have any of the following? Bone or Joint problems, Grommets, perforated Ear Drum, Fever, chest pains? if so, please explain

Are there any other conditions that may affect the treatment? If so, please explain

I confirm that to the best of my knowledge the information I have given is correct and will advise CTTC should anything change. I am aware of no underlying condition that would prevent me from undertaking treatments or may cause any adverse effect.

Signature

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Before your treatment we would like you to tell us a bit about yourself so we can ensure the treatment suits your needs. This form can be completed and submitted online, alternatively we will complete it together on your first visit.

Thank you