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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