Name *

First Name

Last Name

Do you have any allergies? If yes, please give details. Please also include allergies to cleaning products, latex, etc. *

YES

NO

Do you suffer from Diabetes? If yes, what type is it and how is it managed? *

YES

NO

Do you suffer from a cardiac condition? If yes, please outline the condition and management *

YES

NO

Do you have high blood pressure? If yes, is it managed and how? *

YES

NO

Do you suffer from a respiratory condition ? If yes, please outline the condition and management. *

YES

NO

Do you suffer from any digestive problems? If yes, please outline the condition and management. *

YES

NO

Do you suffer from an auto immune disease? If yes, please outline the condition and management. *

YES

NO

Do you have arthritis? If yes, what type and in which joints? *

YES

NO

Do suffer from epilepsy or seizures? If yes, how are they managed and when was the last episode? *

YES

NO

Are you suffering from any contagious condition eg athletes foot etc? If yes, please outline here. *

YES

NO

Are you currently undergoing treatment for cancer? If yes, please outline current stage. *

YES

NO

Have you recently been hospitalised? If yes please give details below. *

YES

NO

Are you currently pregnant? If yes, how many weeks? *

Yes

No

Are you aged over 70? *

Under 70

70 or over

Are your symptoms affecting any of the following?

Your Daily Activities

Your Ability to Work

Your Sleep

Your Ability to Exercise

Your Mental Health

Have you been tested for Covid-19? *

Yes

No

Antigen - Testing for Covid-19 on day of test

Antibody - Possible immunity for Covid-19

Was the test positive?

Yes

No

Do you still have symptoms of Covid-19? *

Yes

No

Are you experiencing post Covid-19 circulatory complications (deep vein thrombosis, micro-embolisms, stroke symptoms or pulmonary embolisms)? *

Yes

No

Have you been in contact with anyone with Covid-19 symptoms within the last 14 days? *

Yes

No

Are you registered with Track and Trace? *

Yes

No

Do you have any severe breathing difficulties or chest pain? *

Yes

No

Do you have any difficulty in waking or confusion? *

Yes

No

Are you currently experiencing a fever above 37.8oC *

Yes

No

Any new - or worsening of - a cough? *

Yes

No

Any loss of sense of smell and / or of taste? *

Yes

No

Are you an NHS frontline worker? *

Yes

No

Are you a carer? *

Yes

No

Are you shielding a vulnerable adult? *

Yes

No

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension and myofascial pain conditions suitable for treatment using soft tissue therapies. If I experience any pain during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a doctor, chiropractor or qualified medical specialist for any mental or physical ailment of which I am aware. I understand the massage therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I declare that the information I have provided is true and correct and I make this declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration. If either I or someone I have been in contact with tests positive for Covid-19 or have been contacted by NHS Test and Trace I will inform you. If you test positive for Covid-19 then you are obliged to inform me due to close contract treatment. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. I acknowledge that should I be late for my appointment the therapist has the right to alter the length of my massage to suit the needs of the clinic schedule. Please click on the link below to bring you to my Terms and Conditions including my cancellation policy. Note that if you experience any symptoms of Covid-19 you can cancel your appointment within the 24-hour cancellation period free of charge. *

I have read and understood the Privacy Policy and agree to the collection and use of my personal data in accordance with the terms of the Privacy Policy. *

I agree

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