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) Asthma Dizziness / fainting / Vertigo Emphysema Shortness of Breath High Blood Pressure Angina Low Blood Pressure Stroke Epilepsy/Seizures Heart Disease Diabetes Rheumatic Fever Frequent Colds Pregnant Memory Loss/ Dementia /Alzheimers Headaches/Migraines Angina (Chest Pain) Heart Murmurs Palpitations Circulatory Problems – Raynauds Syndrome. High Cholesterol Pacemaker Hernia (Type) Arthritis (Type) Rheumatoid, Osteoporosis / fracture related to this. Joint Pain Cancer (Type) Constipation / Incontinence DVT / Varicose Veins Depression 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) ___________________________________________________________________________ 1 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: 2 _________________