Head, neck and body massage
in North Chingford

Name

Email Address

Phone

Date of Birth

Home Address

Post code

Emergency contact

How did you hear about me? How did you hear about me? Website Internet Search Walk in Recommendation from friend or family

Have You Travelled Or come into contact with any highly contagious diseases within the last 14 days?

Have You Received A Covid Vaccine? Have You Received A Covid Vaccine? Yes No

Medical Conditions (Skin) Medical Conditions (Skin) Boils Fungal infections Herpes Simplex Warts/moles Eczema Psoriasis Skin cancer Skin allergies Rashes Burns Severe Sunburn Scars Cosmetic Surgery Bruise easily Other No Skin Condition

If Other Please Specify

Circulatory/Lymph/ Endocrine System Conditions Please Select any applicable Circulatory/Lymph/ Endocrine System Conditions Please Select any applicable Anemia Infection Phlebitis Heart disease/condition High blood pressure Low blood pressure Varicose Veins Diabetes Clotting disorders Edema Lymphedema Hodgkin’s disease AIDS, HIV Chronic Fatigue Syndrome Lupus Cold/flu/fever Hypo/hyperthyroidism Leukemia/lymphoma Bleeding (not including menstruation) Other No Condition

If Other Please Specify

Respiratory System Respiratory System Sinus problems Tuberculosis Asthma Emphysema Other No Respiritory Conditions

If Other Please Specify

Musculo-skeletal System Musculo-skeletal System Fibromyalgia Rheumatoid arthritis TMJ dysfunctio Strains, sprains, tendonitis Bursitis Carpal tunnel syndrome Thoracic outlet syndrome Cramping, spasms, soreness Broken or fractured bones Persistent pain Loss of motion or mobility Difficulty with prolonged standing Unable comfortably lie on front, back or sides Other No Musculo- Skeletal Conditions

If Other Muscolo Skeletal Condition Please Specifiy

Digestive / Urinary System Conditions Digestive / Urinary System Conditions Cirrhosis Ulcer Gallstones Hepatitis Irritable Bowel Syndrome Kidney stones Reflux esophagitis Bladder infection Eating disorder Other No Digestive Urinary Conditions

If Other Digestive / Urinary System Selected Please Specify

Nervous System Conditions Nervous System Conditions Multiple Sclerosis Spinal cord injury Brain injury Numbness/tingling Headaches Stroke Seizure disorder Reduced sensation Other No Nervous System Conditions

If Other Digestive / Urinary System Selected Please Specify

Reproductive System Conditions Reproductive System Conditions Breast cancer Ovarian cysts Painful menstruation Pregnant Prostate cancer Pelvic Inflammatory Disease Other No Reproductive System Conditions

If other please specify

Other Conditions Other Conditions Hearing Impaired Visually Impaired Insomnia Cancer (other than specified above, including undiagnosed lumps) Alcoholism/Substance abuse Caffeine or nicotine user Physical abuse Psychological condition Using over the counter medication Accidents Surgery other than specified above:

Please explain any other conditions

Are you presently under the care of a physician/ physical therapist/ chiropractor? Are you presently under the care of a physician/ physical therapist/ chiropractor? Yes No

If you are presently under the care of a physician/physical therapist/chiropractor Please specify

Do you have your physician’s permission to receive therapeutic massage? Do you have your physician’s permission to receive therapeutic massage? Yes No Not Necessary

Do You regularly exercise? Do You regularly exercise? Yes no

What are your preferred appointment time frames? What are your preferred appointment time frames? 8am-12pm 12pm-5pm 5pm-8:30pm

How has stress affected your health (e.g., anxiety, insomnia, moodiness, muscle tension, etc.)?

Is there a particular area of the body where you are experiencing tension, stiffness, or pain? If yes, please specify below:

How often do you experience symptoms? How often do you experience symptoms? Constantly Frequently Occasionally Intermittently

Have you seen a doctor for these symptoms? Have you seen a doctor for these symptoms? Yes No

Do you have any particular goals in mind for this massage session?

1) I understand that draping will be used during the session. Only the area being worked will be uncovered. 1) I understand that draping will be used during the session. Only the area being worked will be uncovered. By checking, I agree to share my form responses.

2) I understand that at least 24 hours of notice is required for cancellation of an appointment, and that a fee of 50% of the cost of the scheduled service will be charged to me when this courtesy is not provided. 2) I understand that at least 24 hours of notice is required for cancellation of an appointment, and that a fee of 50% of the cost of the scheduled service will be charged to me when this courtesy is not provided. By checking, I agree to share my form responses.

3) I understand that I am to arrive 10 min before my scheduled appointment. This prevents any stress in scheduling to me or the therapist, and allows time to use the facilities, turn off my cell phone, and to relax. 3) I understand that I am to arrive 10 min before my scheduled appointment. This prevents any stress in scheduling to me or the therapist, and allows time to use the facilities, turn off my cell phone, and to relax. By checking, I agree to share my form responses.

4) Opt-In 4) Opt-In By checking, I agree to share my form responses.

5) I understand that if I experience any pain or discomfort during this session, I will immediately inform the therapist so that pressure and/or strokes may be adjusted to my comfort level. 5) I understand that if I experience any pain or discomfort during this session, I will immediately inform the therapist so that pressure and/or strokes may be adjusted to my comfort level. By checking, I agree to share my form responses.

6) I understand that massage is not a substitute for medical examination, diagnosis, or treatment, though it may be a complementary therapy. I understand that massage can increase soreness and/or pain if I do not follow proper precautions following the massage. 6) I understand that massage is not a substitute for medical examination, diagnosis, or treatment, though it may be a complementary therapy. I understand that massage can increase soreness and/or pain if I do not follow proper precautions following the massage. By checking, I agree to share my form responses.

Pregnancy Massage Information and Informed Consent Massage during pregnancy provides many benefits. It enhances blood circulation, increasing the oxygen and nutrients delivered to your baby. It can relieve the sensation of heaviness and aching in your legs caused by swelling or varicose veins. It can optimize your muscle tone, relieve muscle strain, and reduce strain on your joints. Pregnancy massage reduces stress and promotes relaxation, contributing to a healthier pregnancy. If you have been told that your pregnancy is high risk, please notify the therapist. If you wish to receive a massage today, please read and sign the acknowledgement below. I verify that I am experiencing a low risk pregnancy. I stated all my known health conditions on the attached health questionnaire. I understand that I will receive massage therapy for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation. I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part of the aforesaid massage therapist I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist and his/her principals and agents from all claims and liability whatsoever. Pregnancy Massage Information and Informed Consent Massage during pregnancy provides many benefits. It enhances blood circulation, increasing the oxygen and nutrients delivered to your baby. It can relieve the sensation of heaviness and aching in your legs caused by swelling or varicose veins. It can optimize your muscle tone, relieve muscle strain, and reduce strain on your joints. Pregnancy massage reduces stress and promotes relaxation, contributing to a healthier pregnancy. If you have been told that your pregnancy is high risk, please notify the therapist. If you wish to receive a massage today, please read and sign the acknowledgement below. I verify that I am experiencing a low risk pregnancy. I stated all my known health conditions on the attached health questionnaire. I understand that I will receive massage therapy for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation. I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part of the aforesaid massage therapist I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist and his/her principals and agents from all claims and liability whatsoever. By checking, I agree to share my form responses.

Signature

Date