Massage Form – Andrea's Angelic Healing and Wellbeing Centre

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01977361405

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Home
About Us
our services
Who is Andrea
How we work
Event/Calendar
Group support
Book Now

Home
About Us
our services
Who is Andrea
How we work
Event/Calendar
Group support
Book Now

Massage Form

Massage Form

NAME(Required)

DATE OF BIRTH(Required)

DD slash MM slash YYYY

ADDRESS(Required)

POSTCODE(Required)

MOBILE NUMBER(Required)

E-MAIL ADDRESS(Required)

EMERGENCY CONTACT NAME(Required)

EMERGENCY CONTACT MOBILE NUMBER(Required)

Health Information

Please tick all that apply

Please click all Health Issues that apply

Anxiety/Stress

Autoimmune Disease / Disorder

Bleeding Disorder

Blood Clot

Bruise Easily

Bursitis

Cancer / Tumour

Depression

Diabetes

Digestive Problem

Endocrine Disorder

Fibromyalgia

Frequent Headaches

Hearing Loss

Heart Conditions

High Blood Pressure

Infections or Contagious Conditions (e.g. HIV, TB, Fungal Infections, Shingles, etc.)

Kidney Disease

Low Blood Pressure

Please click all Health Issues that apply

Multiple Sclerosis

Muscle Weakness

Neurological Conditions

Neuropathy

Osteoarthritis

Osteoporosis

Phlebitis / Varicose Veins

Respiratory Disorder

Rheumatoid Arthritis

Sciatica

Seizures

Skin Conditions

Stroke / Cerebrovascular accident

Tuberculosis

Tendinitis

TMJ Disorder

Vertigo / Dizziness

Vision Impairment

ARE YOU CURRENTLY RECEIVING ANY MEDICAL TREATMENT?

Leave blank if you are not

ARE YOU PREGNANT?(Required)

Yes

No

DO YOU HAVE ANY ALLERGIES?(Required)

Yes

No

IF YOU HAVE ALLERGIES PLEASE STATE AS OILS ARE USED(Required)

ARE YOU TAKING ANY CURRENT MEDICATIONS?(Required)

Yes

No

DO YOU HAVE ANY AREAS OF SWELLING?(Required)

Yes

No

PLEASE STATE YOUR MEDICATION(Required)

PLEASE STATE WHERE THE AREAS OF SWELLING ARE(Required)

DO YOU HAVE ANY AREAS OF BROKEN SKIN?(Required)

Yes

No

DO YOU HAVE ANY AREAS OF NUMBNESS?(Required)

Yes

No

PLEASE STATE WHERE THE AREAS OF BROKEN SKIN ARE(Required)

PLEASE STATE WHERE THE AREAS OF NUMBNESS ARE(Required)

Massage Information:

HAVE YOU HAD A PROFESSIONAL MASSAGE BEFORE?(Required)

Yes

No

HOW RECENT WAS THE MASSAGE?(Required)

WHAT IS YOUR PREFERRED PRESSURE?(Required)

Light

Medium

Deep

WHAT IS YOU REASON FOR SEEKING A MASSAGE?(Required)

Relaxation

Specific Reason

WHAT IS THE SPECIFIC REASON?(Required)

DO YOU HAVE ANY AREAS OF PAIN OR DISCOMFORT?

PLEASE SIGN AND DATE TO AGREE THE ABOVE INFORMATION IS CORRECT:

CLIENT SIGNATURE(Required)

Date(Required)

DD slash MM slash YYYY

Consent(Required)

By returning this form you confirm you have read the GDPR document on our website and agree

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Contact Info

01977361405

07429 542291 (Out of hours)

[email protected]

61 Bridge Street Castleford, WF10 1HH

G-76MRZY8740

Copyright © 2024 ANDREA’S ANGELIC HEALING WELLBEING CENTRE All Rights Reserved.

Registrations

CNHC Membership

Complementary Medical Association

International Practitioners of Holistic Medicine –

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