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Holistic Massage Consent Record
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Full Name
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Date of birth
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Home address
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Email address
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Mobile number
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Gender
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Male
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In case of emergency contact name & number
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Are you currently under a doctor’s care, if yes please explain why?
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Do you take any medications on a regular basis, if yes please list medications and reasons for taking.
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Have you been recently hospitalised, if yes please give the date and reason.
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Have you had any surgeries, if yes please state why and give dates
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Have you had any accidents or injuries, if yes please state why and give dates
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Are you pregnant?
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No
Maybe
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Do you have or have you had:
High blood pressure
Low blood pressure
High cholesterol
Diabetes
Heart Issues
A stroke
Lightheadedness or fainting
Emphysema
Thyroid or kidney issues
Epilepsy
Asthma
Back pain
Arthritis
Gynecological issues
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Is there anything else you think we should know?
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Today's Date
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