Medical Questionnaire

Please complete this short questionnaire before your treatment — it takes around three minutes and helps us tailor your session safely. Returning clients should update it if anything about your health has changed.

All questions are compulsory. If a question does not apply to you, please enter NA.

Your Details

Full Name *

Phone *

Email *

Post Code *

Address *

About You

How Did You Hear About Us? *

Occupation *

Your Age *

Do You Exercise? *

Received Massage Therapy Before? *

What Are You Looking To Achieve? *

If you’ve had massage before, any details? *

Your Health

Please tick any of the following conditions that apply to you.

Diabetes High Blood Pressure Low Blood Pressure Heart Condition Kidney Condition Liver Condition Recent Surgery Headaches / Migraines Nerve Pain / Damage Neck / Spine Injury Sports Injury Bruises / Abrasions Acute Pain Osteoporosis Blood Clot Varicose Veins Infections Cold / Flu

Any other conditions or injuries we should be aware of? *

Any areas of your body we should not massage? *

I understand massage therapy is for stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand the therapist does not diagnose illness or disease, does not prescribe medical treatment, and does not perform spinal manipulation. I will inform the therapist of any current conditions at the time of each visit. I understand any inappropriate activity or advances towards the therapist will be reported to the authorities immediately. *

Client’s Signature (type your full name) *

Date *

Address:

Serendipity Massage Therapy & Wellness
Floor 1, Suite 48-50
Central Chambers
93 Hope Street
Glasgow City Centre

Email:

[email protected]

Phone:

0141 673 6630

Website:

serendipitymassage.co.uk

Get driving directions to Serendipity Massage Therapy & Wellness:

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