Holistic Massage Form | eternalbeing

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Name(Required)

Title First Last

Address(Required)

Street Address Address Line 2 City County Post Code

Email(Required)

Phone(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Occupation(Required)

Where did you hear about us?(Required)

GP's Name and Address(Required)

Street Address Address Line 2 City County Post Code

Are you seeing your doctor at present?(Required)

Yes

Please give details

List any medications, supplements you are taking

List any medical conditions you have

List any surgical procedures you have had and the dates

List any allergies you may have

Contraindictions Requiring Medical Permission

In circumstances where medical permission cannot be obtained clients must give their informed consent in writing prior to treatment.

Pregnancy

Cardio vascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)

Haemophilia

Osteoporosis

Arthritis

Nervous/Psychotic conditions

Epilepsy

Recent operations

Diabetes

Asthma

Kidney infections

Bells Palsy

Trapped/Pinched nerve (e.g. sciatica)

Inflamed nerve

Cancer

Postural deformities

Spastic conditions

Whiplash

Slipped disc

Undiagnosed pain

When taking prescribed medication

Acute rheumatism

Any condition already being treated by a GP or Another complementary practitioner?

Any dysfunction of the nervous system (e.g. Muscular sclerosis, Parkinson’s disease, Motor neurone disease)

Contraindictions That Restrict Treatment

Fever

Contagious or infectious diseases

Under the influence of recreational drugs or alcohol

Diarrhoea and vomiting

Skin diseases

Undiagnosed lumps and bumps

Localised swelling

Inflammation

Varicose veins

Pregnancy (abdomen)

Cuts

Bruises

Abrasions

Scar tissues (2 years for major operation and 6 months for a small scar)

Sunburn

Hormonal implants

Abdomen (first few days of menstruation depending how the client feels)

Haematoma

Hernia

Recent fractures (minimum 3 months)

Cervical spondylitis

Gastric ulcers

After a heavy meal

Conditions affecting the neck

Written Permission Required

GP / Specialist

Informed Consent

Written Permission Upload

Max. file size: 300 MB.

Muscular / Skeletal problems

Back

Aches/Pain

Stiff joints

Headaches

Digestive problems

Constipation

Bloating

Liver/Gall bladder

Stomach

Circulation

Heart

Blood pressure

Fluid retention

Tired legs

Varicose veins

Cellulite

Kidney problems

Cold hands and feet

Gynaecological

P.M.T

Menopause

Irregular periods

H.R.T

Pill

Coil

Other

Nervous system

Migraine

Tension

Stress

Depression

Immune system

Sore throats

Colds

Chest

Sinuses

Prone to infections

Regular antibiotic / medication taken?(Required)

Yes

Which ones?

Herbal remedies taken?(Required)

Yes

Which ones?

Ability to relax(Required)

Good

Moderate

Poor

Sleep patterns(Required)

Good

Moderate

Poor

Do you see natural daylight in your workplace?(Required)

Yes

Do you work at a computer?(Required)

Yes

How many hours?

Do you eat regular meals?(Required)

Yes

Do you eat in a hurry?(Required)

Yes

Do you take any food / vitamin supplements?(Required)

Yes

Which ones?

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

Fresh fruit(Required)

Fresh vegetables(Required)

Protein (source)(Required)

Dairy produce(Required)

Sweet things(Required)

Added salt(Required)

Added sugar(Required)

How many units of these drinks do you consume per day>

Tea(Required)

Coffee(Required)

Fruit juice(Required)

Water(Required)

Soft drinks(Required)

Others(Required)

Do you suffer from food allergies?(Required)

Yes

Do you suffer from bingeing?(Required)

Yes

Do you suffer from overeating?(Required)

Yes

Do you smoke?(Required)

Yes

How many per day?

Do you drink alcohol?(Required)

Yes

How many units per day?

Do you exercise?(Required)

None

Occasional

Irregular

Regular

Types of exercise

What is your skin type?(Required)

Dry

Oil

Combination

Sensitive

Dehydrated

Do you suffer / have you suffered from…

Dermatitis

Acne

Eczema

Psoriasis

Allergies

Hay

Fever

Asthma

Skin cancer

Stress level (1-10)(Required)

10 being the highest

Reason for treatment(Required)