Health Form

Comments

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Mobile Number(Required)

House Number & Post Code(Required)

Date of Birth(Required)

Medical Conditions(Required)

Have you ever had any of the following, Arthritis, Diabetes, Fibromyalgia, Blood Clots, Heart Issues, Stroke, Joints replaced, other major illness, surgery etc. If so list which ones

Medications(Required)

Are you on any medications? If so which ones?

Do you have any allergies?(Required)

If you have any allergies please list these below

Are you currently in any pain?(Required)

If yes please give details, if not please type no.

Goals(Required)

What are your goals for this treatment?

Type of massage experience required(Required)

Sensual Only - please confirm below that you are in agreement with being massaged intimately

Yes, No or N/A

Do you or have you ever suffered from an infectious illness or sexually transmitted disease? Please state what and when(Required)

Any body parts not to be touched, i.e. Head, Feet, etc (Very Important)(Required)

Where did you hear about us?(Required)

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