Indian Head Massage Form

Step 1 of 4

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Name(Required)

Title First Last

Address(Required)

Street Address Address Line 2 City County Post Code

Email(Required)

Phone(Required)

Occupation(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Where did your hear about us?(Required)

GP's Name and Address(Required)

Name and 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

Have you had a recent head or neck injury?(Required)

Yes

Please give dates and details

Have you had a cardiovascular condition?(Required)

Yes

Please give dates and details

Have you had thrombosis or embolism?(Required)

Yes

Please give dates and details

Have you had high or low blood pressure?(Required)

Yes

Please give dates and details

Have you had dysfunction of the nervous system(Required)

Yes

Please give dates and details

Have you had cancer/chemotherapy or radiotherapy?(Required)

Yes

Please give dates and details

Have you had a recent haemorrhage?(Required)

Yes

Please give dates and details

Have you cuts or abrasions in the treatment area?(Required)

Yes

Please give dates and details

Have you had a recent operation?(Required)

Yes

Please give dates and details

Do you have diabetes?(Required)

Yes

Please give dates and details

Do you have epilepsy?(Required)

Yes

Please give dates and details

Do you have a spastic condition?(Required)

Yes

Please give dates and details

Do you have migraine/severe headaches?(Required)

Yes

Please give dates and details

Do you have a skin/scalp or hair disorder or infection?(Required)

Yes

Please give dates and details

Do you have recent scar tissue / bruises / open cuts / large moles / lumps / other swellings?(Required)

Yes

Please give dates and details

Do you have any allergies?(Required)

Yes

Please give dates and details

Do you have any medical conditions (not mentioned above)?(Required)

Yes

Please give dates and details

Are you currently under the influence of drugs or alcohol?(Required)

Yes

Please give dates and details

Current medical treatment

Current medication (list dosages)

GP referral required

Yes

General state of health

Do you smoke?(Required)

Yes

Average per day

Do you drink alcohol?(Required)

Yes

Average per day

How many glasses of water do you drink daily?(Required)

How woulld you describe your diet?(Required)

How would you describe your skin condition?(Required)

Normal

Dry

Combination

Sensitive

Mature

How would you describe your posture?(Required)

Good

Average

Poor

How would you describe your muscline tone?(Required)

Good

Average

Poor

What's your height?(Required)

What's your weight?(Required)

How would you describe your stress levels?(Required)

High

Medium

Low

How would you describe your sleep patterns?(Required)

Good

Average

Poor

Exercise undertaken / lifestyle

Do you follow a regular exercise programme?(Required)

Yes

Please give details

Do you have any hobbies / time set aside for relaxation (give details)

Have you had an Indian head massage treatment before?(Required)

Yes

Please give details of previous treatments and success

Are you currently haning any other forms of alternative / complementary treatment? (Please give details)

Declaration

I declare that the information I have given is true and correct and that, as far as I am aware, I can undertake treatment with this establishment without any adverse effects. I have been fully informed about contraindications and am therefore willing to proceed.