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Consultation Form

Once you have confirmed your booking, please take a few minutes to complete the consultation form below. Doing so now will mean not having to complete it when you have your appointment allowing more time for your treatment. You should normally only have to do this once for your first booking. Thank you. 

The Clinic of Massage Consultation Form

Please fill out the following form
in order to participate in treatment.

Are you suffering from a medical condition, illness, or injury?
Do you suffer from chronic pain?
Have you been hospitalized in the last 12 months?
What is your reason for booking?
Are you taking any medication?
Have you had a massage treatment before?
How would you describe your stress levels?
How would you describe your sleep pattern?
Do you eat fruits & vegetables?
Do you drink alcohol?
Do you take part in any regular exercise?
Do you have diabetes?
Do you have any varicose veins?
Do you have any recent cuts, abrasions or bruising?
Do you have osteoporosis?
Do you suffer from any neck, back or shoulder pain?
Do you suffer from any elbow or wrist pain?
Have you ever had or do you have cancer?
Do you suffer with shortness of breath or persistent coughing?
Do you have problems holding or passing water (urine)?
Are you menopausal?
Are there any other health/medical condition not mentioned?
How would you describe your energy levels?
Are you on any special diet?
Do you drink water daily?
Do you smoke?
Do you suffer from unstable blood pressure?
Do you have any skin disorders?
Do you suffer from any swelling/oedema?
Do you have any recent fractures or sprains?
Do you suffer from arthritis?
Do you suffer from any hip, knee or ankle pain?
Do you suffer from any allergies?
Do you have chess pain, or palpitations?
Do you suffer with constipation, diarrhoea or nausea?
Are there changes to your menstrual cycle?
Are you Pregnant?
Do you have GP approval to receive treatment?
Upload File

Thanks for submitting!

You can also download the consultation & GP consent forms below. Please email the completed forms to clinicofmassageinfo@gmail.com 
Please complete pages 1-4 only

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