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CLIENT DETAILS

COMPLETE YOUR DETAILS HERE

This form should be completed if you are a new clients or if you have new health or medical information to report before your appointment.

ANY QUESTIONS LET ME KNOW;

Email: [email protected]

Phone: 07822 013386

First Name *

Last Name *

Phone *

Email *

Leyanne Hodgson can contact me using the details I provide in relation to her services & my bookings.

Emergency Contact Name *

Emergency Contact Number *

Are you on any medication? *

Yes

Please give details:

Do you have any allergies? *

Yes

Please give details:

Have you received massage therapy or bodywork before? *

Yes

Tell me about your past experiences:

Do you exercise? *

Yes - Daily

Yes - Weekly

Not much

Never

Tell me more about your typical exercise routine:

Please mark any of the following that apply to you: *

Neck injury

Infection

PMS

Emotional changes

Sinus congestion

Headaches

Cold virus

Flu

Allergies

Kidney Alignment

Sports Injury

Phlebitis

Bruises

High Blood Pressure

Low Blood Pressure

Varicose Veins

Acute Pain

Grief Process

Recent Surgery

Open Wounds

Osteoporosis

Chronic Pains

Blood Clot

Fever within the last 24hrs

Wear Contacts

Alcohol within the last 24hrs

Drug use within the last 24hrs

Other

Please give more details and/or report other things of importance about your health & wellbeing here:

I understand that massage therapy is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment nor perfom spinal manipulations. I will inform the therapist of my current condition at the time of each visit. *

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