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Massage Consultation Form

Welcome to your consultation. Please fill out the following information to help us provide the best service possible.

Full Name*

Email*

Phone Number*

Date of Birth*

Address

Country/Region*

Address*

City*

Zip / Postal code*

Medical History*

Heart Disease

Diabetes

High Blood Pressure

Allergies

Asthma

Chest Pain

Shortness of Breath

Persistent Coughing

Palpitations

Constipation

Diarrhoea

Nausea

Problems passing water (urination)

Burning sensation on urination

Changes in frequency of urination

Changes in menstrual cycle

Pregnant

Menopausal

Other

None

Are you on any prescribed medication?*

Yes

No

If yes, please list the medications

Any major illnesses?*

Yes

No

If yes, please specify

Any major accidents?*

Yes

No

If yes, please specify

Any major operations?*

Yes

No

If yes, please specify

Anything else not mentioned?

Gender*

Male

Female

Eating Habits*

Balanced

High Protein

Vegetarian

Vegan

Low Carb

Other

Fluid Intake*

Adequate

Inadequate

Excessive

Other

Exercise*

Regular

Occasional

Rare

None

Well-being*

Excellent

Good

Fair

Poor

Reason for Visit*

Relaxation

Pain Relief

Stress Relief

Injury Recovery

Other

Areas of Tightness/Tension*

Neck

Shoulders

Back

Legs

Arms

None

Other

Consent to Treatment*

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Contact Conscious Spa

07709 880 566

info@conscious-spa.co.uk

First name*

Last name*

Email*

Phone

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