Massage Medical Consent Form Massage Medical Consent Form Contact Details: Full Name: * DOB: * Occupation: * Were you Referred to Zané Barlow Massage by a friend or family member? * Yes No If yes, who was the referee? Health / Medical History: Do you have any injuries and/or complaints at present * Yes No If yes, please let me know what these injuries and/or complaints are Have you had any operations in the last 5 years? * Yes No If yes, please state which operations you had Do you, or have you ever suffered from any of the following conditions? * Asthma Epilepsy Stroke Heart Attack Osteoporosis Varicose Veins Cancer Migraine High / Low Blood Pressure Diabetes None Do you take natural, recreational and/or pharmaceutical medication? * Yes No Are your bowel movements regular? * Yes No Are you pregnant and/or lactating? * Yes No n/a Is your menstrual cycle regular? * Yes No n/a Please indicate your skin type? * Oily Dry Combination Mature Sensitive Do you have any allergies, or are you allergic to any oils? * Yes No If yes, please let me know what allergies you have Do you smoke? * Yes No Lifestyle: Do you drink tea/coffee? * Yes No Do you drink alcohol? * Yes No How many hours per week do you spend taking time out for yourself? * Which best describes your diet? * Heavy Meat consumption Fast Food Rich Foods (lots of dairy & desserts) Vegetarian or Vegan Combination Do you do regular exercise? * Yes No Do you suffer from any of the following? * Fatigue Stress Rage Anxiety Phobias Depression Post Natal Depression Nervousness Anger Menopause Addiction Mood Swings Insomnia Anorexia PMT None I understand that the massage therapist will consider information about my physical condition, medical history, lifestyle, stress levels, medications and any areas of physical pain that could affect my massage therapy outcome. I also understand that all information provided will be used purely to help structure the treatment session to achieve my health and wellness goals. I declare that the information that I have given is correct and wish to proceed with treatments. I agree to disclose any medical condition, to determine my overall health and wellness goals Terms and Conditions: I want you to know how my service works and why and how I handle your data. Please state that you have read and agreed to these terms and conditions. I have Read and Agree to the Terms and Conditions * Yes reCAPTCHA Submit
