Your Email
Your First Name
Your Last Name
Date of Birth
—Please choose an option—12345678910111213141516171819202122232425262728293031—Please choose an option—JanFebMarAprMayJunJulAugSepOctNovDec—Please choose an option—19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015
Address
Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Do you regularly exercise? YesNo
Do you follow a specific diet? YesNo
Do you smoke? YesNo
How well do you sleep? Well (more than 8 hours)OK (7-8 hours)Could be better (less than 7 hours)
Do you feel that stress is a problem for you? YesNo
Reason for massage e.g. relaxation, specific pain...
Do you suffer from migraines/headaches? YesNo
Are you currently seeing a GP or other practitioner and/or taking any prescribed medications? YesNo [group if-gp] Please give details of any prescribed medications, and/or what you are seeing your GP/other practitioner for. [/group]
Do you have any allergies? (e.g. to nuts) YesNo [group if-alergies] Please give details of your allergies. [/group]
Do you have any of the following conditions?
High blood pressure
YesNo
Low blood pressure
Any cardiovascular conditions
Epilepsy
Asthma
Diabetes
Arthritis
Osteoporosis
Cancer
Oedema/swelling
Dysfunction of the nervous system
Fever
Contagious or infectious diseases
Skin disorders
Varicose veins
Recent cuts/abrasions/bruises
Recent fractures/sprains - within the last 3 months
Scar tissue from surgery - within 2 years for major, or 6 months for minor
Back problems
Under the influence of alcohol or drugs on the day of your treatment
Planning to eat a heavy meal 2 hours before treatment
Please use this space to give further details if you checked any of the above boxes.
List any other medical condition that you have that is not listed above, or anything else you feel is relevant to your treatment.
I am happy to receive emails relating to Good Balance.
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