consultation form

Your health profile

Fill out the form below to tell us about your current health.

Name
Date of birth
Address
Phone
Email
Occupation
GP Surgery
Are you currently seeing a GP/Health Practitioner?
Is there any chance you could be pregnant?
Do you have any allergies?
Allergies
Are you currently suffering from a fever or illness?
Do you suffer from diarrhoea or constipation?
Do you suffer from DVT or Thrombosis?
Epilepsy
Epilepsy?
Arthritis?
Diabetes Type 1 or Type2?
Cancer (present or in the past)?
Heart, Blood or Lung Conditions?
High or Low Blood Pressure?
Slipped Disks, Whiplash or Bone Damage?
TB/Osteoporosis?
Headaches / Migraines?
Skin conditions – including bruising/scars etc…?
Any other chronic/serious illnesses (present or historic)?
Chronic/serious illnesses (present or historic)
Have you had any recent or past operations/surgery?
Is there anything else regarding your health that you feel may be relevant, not mentioned above?
Your exercise per week
Areas of tension
I confirm that I have obtained GP written or verbal consent to receive massage/reflexology in light of the health issues stated above
I am fully aware that the medical conditions stated above in bold are considered contra-indications to massage/reflexology, and until I obtain the requested consent from my GP, I hereby take full responsibility in my participation of the therapy and any effects or harm that may result from all therapy sessions with Target Therapies.
On submitting this document, you agree to refrain from consuming alcohol or drugs within 12 hours of a treatment, and agree to update the therapist of any changes to your health prior to each session.
submit