Indian Head Massage Client Consultation Form by cwj21439

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									                                         Indian Head Massage
                                     Client Consultation Form

Name:

Address:


Tel:
D.O.B/Age:
MEDICAL QUESTIONNAIRE:
Do you suffer, or have you suffered with any of the following?
Any recent head or neck injury?                     Yes / No
Severe bruising on an area to be treated?           Yes / No
Epilepsy?                                           Yes / No
Recent haemorrhage?                                 Yes / No
High or low blood pressure?                         Yes / No
Migraines?                                          Yes / No
Thrombosis or embolism?                             Yes / No
Diabetes?                                           Yes / No
Muscle spasms?                                      Yes / No
Dysfunction of the nervous system?                  Yes / No
Skin disorders?                                     Yes / No
Scalp infections?                                   Yes / No
Cuts or abrasions on the areas to be treated?       Yes / No
A recent operation?                                 Yes / No

Are you pregnant?                                    Yes / No
Are you currently taking any medication/s?           Yes / No
Name of GP and address:



LIFESTYLE
Do you drink alcohol?                                Yes / No
  If so, how often?
Do you smoke?                                        Yes / No
  If so, how many?
Additional notes:



CLIENT DECLARATION:
The information I have given regarding my medical details is accurate.
I will promptly notify the therapist of any future changes to my health.
Signed:                                              Date:

								
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