MOBILE WELLNESS THERAPY
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Consultation Form
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0813964559
:www.mobilewellnesstherapyspa.co.za
*Client information release form
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(Intake form)
{Each client should fill this form at least once}
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Name:
Adress:
Phone:
Date of birth:
Referred by:
In case of emergency:
Name:
Phone:
General &Medical Information
-Have you ever had a professional massage? __
-Do you frequently suffer from stress?__
-Do you experience frequent headaches?__
-Are you pregnant?__
-Are you wearing contact lenses?__
-Are you diabetic?__
-Do you have high blood pressure?__
If yes to above, are you taking medication for this?__
-Are you epileptic?__
*If yes to any question in this section,please explain as clearly as possible *
-Have you ever had any surgery?__
-Have you had any broken bones in the past two years?__
-Do you have any tension or soreness in a specific area?__
-Do you have cardiac or circulatory problems?__
-Do you suffer from back pain?__
-Do you have any numbness or stabbing pains anywhere?__
-Do you have any other medical condition I should be aware of?__
-Are you sensitive to touch/pressure in any area?__
Any questions answered yes to, will be discussed prior to your session.
Thank you!
*PLEASE TAKE A MOMENT AND READ THE FOLLOWING
INFORMATION AND SIGN WHERE INDICATED:*
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Name:
*I understand that the massage/body work I receive is provided for the basic purpose of relaxation,stress reduction, and relief of muscular tension. If i experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokesmayy be adjusted to my level of comfort.
I further understand that massage should not be construed as a substitute for medical examination,diagnosis.prescribe or treat any mental illness, and that nothing said in the course of the session (s) given,should be construed as such.
Because massage is contraindicated (should not be done) under certain medical condition, i affirm that I have stated all my medical conditions And answered all questions honestly. I agree to keep practitioner updated As to any changes in My medical profile and understand that there shall be no liability only practitioners pan should I forget to do so.
It is also Understood and illicit or sexual suggestive remarks or advances made by me, will result in immediate termination of session and I’ll be liable For the full scheduled appointment```.
Signed:_____ Date:____
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Practitioner:___ Date:___
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*Progress Chart*
Date:__
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Client’s Name:__
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Duration:__
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Client’s comments:__
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Date__
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Client’s Name__
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Therapist’s comments __
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Thank you for booking with us
Your support is greatly appreciated!
By Management!!
