Male Masseur for Aromatherapy Massage, Edinburgh Glasgow Fife Lothians visiting service. Call 07527 841 024
Massage - Male Masseur - Edinburgh, Glasgow, Scotland
 

Consultation Form

Forename:
Surname:
Tel:
Date of Birth:

 

Address:

 

Sex:

Marital Status:

 

Occupation:

 

Doctors Details (inc address & tel no)

 

Have you ever had or suffering from cancer ?

 

Do you have any of the following allergies?

Nut/oil allergies Yes No
Hay fever Yes No
Sinusitis Yes No
Eczema Yes No
Psoriasis Yes No
Any other (please give details below)    

 

Are you ?

Diabetic Yes No
Epileptic Yes No

 

Are you/could you be pregnant ?

Yes
No

 

Do you suffer from any of the following?

Heart problems
Yes
No
High blood pressure
Yes
No
Low blood pressure
Yes
No
Varicose veins
Yes
No
Multiple sclerosis
Yes
No
Arthritis
Yes
No
Broken bones/strains
Yes
No
Kidney problems
Yes
No
Indigestion
Yes
No
Gallstones
Yes
No
Constipation
Yes
No
Diarrheoea
Yes
No
Bronchitis
Yes
No
Colds/flu
Yes
No
Asthma
Yes
No
Eye problems
Yes
No
Ear problems
Yes
No
Menstruation problems
Yes
No
Birth pill
Yes
No
PMT
Yes
No
Menopausal
Yes
No
Migrane/headaches
Yes
No
Insomnia
Yes
No
Nervous stress
Yes
No
Anxiety
Yes
No
Depression
Yes
No
   
Spinal problems  
Posture
Yes
No
Neck/shoulders
Yes
No
Lumber
Yes
No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have any other medical condition/illness ? Please give details:

 

Are you on medication ? Please give details :

 

Are you intending to sunbathe in the next 24 hours ?

Yes
No

 

Do you ?

Take supplements Yes No
Smoke Yes No
Drink alcohol Yes No

 

Some patients may have the following symptoms for upto 48 hours after a therapy: headaches, emotionally upset, lethargic, energised, flu symptoms, achy limbs.

This is a result of your mind and body absorbing the essential oils.

 

I agree the above is accurate

Clients name

Date

 

 
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Male Masseur for Aromatherapy Massage, Edinburgh Glasgow Fife Lothians visiting service. Call 07527 841 024