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Personal details












General state of health

Do you exercise regularly?

YesNo

Are you taking any medication?

YesNo

Are you on any special diet?

YesNo

Do you smoke?

YesNo

Do you drink alcohol?

YesNo

How would you describe your energy levels?

HighMedLow

How would you describe your stress levels?

YesMedLow

Have you ever had a massage treatment?

YesNo



*Female clients only

Could you be pregnant?

YesNo

Are you breastfeeding?

YesNo

Have you had an IUD fitted in the last 12 weeks?

YesNo

Conditions and/or symptoms

Do you suffer from unstable blood pressure?

YesNo

Do you suffer from any heart disorders?

YesNo

Do you suffer from phlebitis?

YesNo

Do you have a history of thrombosis/embolism?

YesNo

Do you have epilepsy?

YesNo

Do you have a dysfunction of the nervous system?

YesNo

Do you suffer from any infectious diseases?

YesNo

Do you suffer from any skin disorders?

YesNo

Do you have any severe bruising?

YesNo

Do you have any recent scar tissue?

YesNo

Have you recently suffered from a haemorrhage?

YesNo

Do you have any varicose veins?

YesNo

Do you suffer from any swelling/oedema?

YesNo

Do you have any recent cuts or abrasions?

YesNo

Have you recently had any operations?

YesNo

Have you recently had any inoculations?

YesNo

Have you ever had or do you have cancer?

YesNo

Do you have any recent fractures or sprains?

YesNo

Are you currently suffering from a fever?

YesNo

Do you have diabetes?

YesNo

Do you have osteoporosis?

YesNo

Do you suffer from arthritis?

YesNo

Do you suffer from any back problems?

YesNo

Do you suffer from any allergies?

YesNo

Have you recently consumed alcohol?

YesNo

Have you recently consumed a heavy meal?

YesNo

Do you have any other medical condition?

YesNo