Consultation Form

Thank you for taking a moment to complete this form before your session.  It helps me understand what’s going on in your body, what your goals are, and how to tailor your massage safely and effectively.

If you’re coming for the Free Taster Session, filling this in beforehand means we can focus fully on you when you arrive.  If you’re an existing client, updating your details ensures your treatment stays accurate and up to date.

All information is confidential and secure.

Thanks — I appreciate you taking the time.

Name
What are your contact preferences?
This is for GDPR compliance to make sure I contact you in the way you want. Please choose one or all.
The type of work you do can indicate how pain develops (ie office work, lots of driving, manual work etc)
Medical History
Select all that apply. If you have a medical condition that isn't listed, you can add them in medical history details below
Please give details of an medications you are taking. Is there anything about your health and wellbeing you would like to tell us.
Pregnancy can be a contrindication for massage if you are up to 14 weeks.
Please let us know of any areas of pain. List them in the order of your priority. Say how they are affecting your daily life
Are there any activities or movements that you are avoiding?
Is there anything that improves your current problems.
Selected Value: 0
Rate your mood (0=poor, 10=excellent)
Selected Value: 0
Rate your stress levels (0 =poor, 10=no stress)
Selected Value: 0
Rate the quality of your sleep (0=poor, 10=no sleep problems)
What are your reasons for seeking treatment ?
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