Massage Treatment Questionairre

HomeMassage Treatment Questionairre
Any personal information you do not wish to enter online can be filled in in pen on the paper copy of this form when we meet, and then only be stored in a secure filing cabinet in my office.  
I am not allowed to massage you without you completing this questionnaire and if you do it prior to the appointment it will save time during the appointment leaving more time for massage.



    Cardiovascular Questions

    Question No Yes Comment
    Chest Pain? No Yes
    Shortness of Breath? No Yes
    Persistent Coughing? No Yes
    Palpitations? No Yes

    Digestive Questions

    Question No Yes Comment
    Constipation? No Yes
    Nausea? No Yes
    Diarrhoea? No Yes

    Urinary Questions

    Question No Yes Comment
    Problems Passing Water? No Yes
    Burning Sensation on Urination? No Yes
    Changes in frequency of urination? No Yes

    Reproduction Questions

    Question No Yes Comment
    Changes in menstrual cycle? No Yes
    Pregnant? No Yes
    Menopausal? No Yes

    General Health Questions

    Question No Yes Comment
    Are you on any prescribed medication? No Yes
    Any major illnesses? No Yes
    Any major accidents? No Yes
    Major Operations? No Yes
    Anything else not mentioned? No Yes