Medical Questionnaire

Medical Questionnaire
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date Date Picker Icon
Email *
example@example.com
Phone Number *

Address *

Street Address
Street Address Line 2
City	County
Postcode	Country

Next of Kin *

First Name Last Name
Next of Kin Contact Telephone *
What do you do for a living?
What are your hobbies?
GP Name *

First Name Last Name

GP Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please tell me about any medical conditions here:
Do you take any medication? *

Yes No
Medication details, if relevant
Please tell me about any surgery you've had, recent or otherwise
Please tell me about any injuries, recent or otherwise
Are you allergic to anything? *

Yes No
Please give details of any allergies here
Women, is there any chance you might be pregnant?

Yes No
If you are pregnant, please fill out the section below:
What is your due date?

Month Day Year
Date Date Picker Icon
Have you had any complications so far in your pregnancy?

Yes No
If yes, please give details here:
I confirm that I have provided true and accurate information to the best of my knowledge. I accept that Essential Massage and Soft Tissue Therapy ('Essential') will use the information here only as a baseline for treatment and that any omission which affects my treatment is not the fault of Essential.

Essential undertakes to keep all information provided here confidential in line with the requirements of GDPR (2018). Essential further undertakes to only release this information to other practitioners with your express written permission. Please be aware that the law currently requires that medical records are kept for 7 years post-treatment for adults and until the age of 21 for anyone treated before they turned 18. All records will be securely destroyed after the relevant time period has elapsed.

Essential will not contact you without permission, as detailed below. Ticking the box confirms that you agree to these Terms and Conditions and are happy to proceed with treatment on this basis.
Acceptance of terms and conditions *

I agree to the above & am happy to be e-mailed details of current offers I agree to the above & do not want to be contacted outside of booked appointments
Thank you for your time in completing this form - we look forward to meeting you soon!
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Medical Questionnaire

If you are pregnant, please fill out the section below: