Health Questionnaire for Massage Therapy with a

Health Questionnaire for Massage Therapy
The following information is required for your safety and health. These details will be treated in the
strictest of confidence. It may, however, be necessary for you to consult your GP before any treatment
may be given.
Contact Information
Name: _______________________________________Date of Birth: ____________________________
Home Address:
City _________________________________________Post Code: ______________________________
Email: _______________________________________ Mobile: _________________________________
Occupation: __________________Leisure pursuits: ___________________________________________
How did you hear about BodyMpower? Website / Leaflet / internet Ad / Other – please list______________
Referred by: ___________________________________
Medical History & Details
Have you or do you suffer from any of the following?
(Please tick &/or give details)
Dizziness / fainting / Vertigo
Shortness of Breath
High Blood Pressure
Low Blood Pressure
Heart Disease
Rheumatic Fever
Frequent Colds
Memory Loss/ Dementia
Angina (Chest Pain)
Heart Murmurs
Circulatory Problems –
Raynauds Syndrome.
High Cholesterol
Hernia (Type)
Arthritis (Type) Rheumatoid,
Osteoporosis / fracture related to
Joint Pain
Cancer (Type)
Constipation / Incontinence
DVT / Varicose Veins
If you have ticked one or more, please give details:
Are you on prescribed medication, herbs or supplements (including contraception)? Y
N (If yes, give details)
Do you have any allergies? Y N (If yes, give details)
Do you have any contagious skin conditions/disease? Y N (If yes, give details)
Have you ever had surgery? Y N (If yes, give details) ______________________________
Have you ever had any broken bones? Y N (If yes, give details) _____________________
Do you suffer from back pain? Y N (If yes, give details) ____________________________
Do you have tension/soreness in a specific area? Y N (If yes, give details)
Do you have numbness/tingling/stabbing pain anywhere? Y N (If yes, give details)
Do you have any sensitivity on skin? Y N (If yes, give details) _______________________
Do you experience stiff, swollen or painful joints? Y N (If yes, give details)
Are these or any other injuries aggravated by exercise? Y N (If yes, give details)
Do any areas need to be avoided, due to discomfort it may cause you? Y N (If yes, please
circle or give details)
Acne, Dermatitis, Hives, psoriasis, Moles, Burns, Ulcer, Open Wounds, Bruising, Varicose
Veins, Fracture, Sprain, Bursitis, Muscular Haematoma, Other
Are special precautions required for your massage? Y N __________________________
Do you have difficulty lying on your front, back, side? Y N ________________________
I, ____________________________________ (print your name), understand that the massage I
receive is provided for the basic purpose of relaxation and relief of muscular tension. If I
experience any pain or discomfort during this session, I will immediately inform the therapist so that
pressure and/or strokes may be adjusted to my level of comfort.
I affirm that I have stated all my known medical conditions and answered all questions honestly. I
agree to keep the therapist updated as to any changes in my medical profile and understand that there
is no liability on the therapist’s part should I fail to do so.
In the event that I become injured either directly or indirectly as a result, in whole or in part of the
aforesaid massage therapist I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist and
his principals and agents from all claims and liability whatsoever.
Signature: _____________________________________________ Date: