Massage Consultation Form

I am frequently asked what does the short consultation I give at the beginning of a massage session cover and why do I need to give one.


Massage consultation

The reason I need to give one is pretty simple - Putting aside the fact that my insurance would be void otherwise, I give a consultation for your safety and to benefit your health. Although essential oils and massage are totally safe when administered professionally by a qualified therapist, there are certain contraindications that require special attention. Regardless of how happy the ending may be, if you go for a massage and the therapist does not give you a consultation you need to be asking yourself why not, and do they really have my safety in mind!!


All your information is subject to data protection and should be treated in the strictest confidence. So there is no reason not to be doing a consultation especially as it only takes a moment to complete. See for yourself below:


Date of Initial Consultation: Client reference number:

Massage Consultation Form

General Client Information


Name: D.O.B.:

Tel: Email:


Do you suffer from any of the following conditions:

Epilepsy

Diabetes

Asthma

Heart condition

High or low blood pressure

Circulatory disorder

Thrombosis

Recent haemorrhage or swelling

Varicose veins

Skin disorder

Abdominal complaint

Dysfunction of the nervous system

Recent operation

A potentially fatal or terminal condition


Are you currently under GP/ Hospital care? Yes/No

If yes, please give details below:

Treatment: Medication:

Do you suffer from any nervous or stress related problems?

Do you suffer from any of the following urinary problems?

Do you suffer from any of the following digestive problems?

Do you suffer from any of the following respiratory problems?

Do you suffer from any of the following circulation problems?

Do you suffer from any of the following skin complaints?


How would you describe your Sleep pattern:

Restless/Excellent sleep/Waking for bathroom


Would you consider your stress levels to be

Average/High/Low


Would you say your energy levels are

Average/High/Low


Please give details of your typical daily diet:


Type of exercise taken:


Do you smoke? If so how many per day?


Weekly alcohol intake (units):


Are you currently having any complementary treatment?

Have you tried aromatherapy or any other complementary therapies before?


In order of priority, please list any issues that you would like treated during the sessions.

Issue 1: Issue 2: Issue 3:


Client signature:

Therapist’s signature:

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