Screening Document
Smart Massage Therapy
Name
*
First Name
Last Name
Gender
Male
Female
Prefer not to say
Other
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Mobile Phone Number
*
Format: 00000 000000.
Home Phone Number
Format: (00000) 000000.
Email Address
*
example@example.com
Date of Birth
*
/
Day
/
Month
Year
Date
Occupation
GP’s Name
GP Surgery
*
GP Surgery Phone Number
Format: (00000) 000000.
GP Surgery Address
Street Address
Street Address Line 2
City
County
Post Code
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Are you currently suffering from, or have you ever suffered from any of the following conditions?
Hypertension, atherosclerosis, coronary artery disease, cardiac arrest, thrombosis, varicose veins or any other cardiovascular disorder?
*
Yes
No
Cancer
*
Yes
No
Haemophilia
*
Yes
No
Diabetes
*
Yes
No
Grave’s disease, lupus, rheumatoid arthritis, celiac disease or any other autoimmune disorder
*
Yes
No
Epilepsy, multiple sclerosis, Parkinson’s disease or any other nervous system disorder
*
Yes
No
Bursitis
*
Yes
No
Periostitis
*
Yes
No
Myosotis ossificans
*
Yes
No
Psoriasis, impetigo, boils, shingles, athletes foot or any other skin disorder
*
Yes
No
Allergic reaction of any kind
*
Yes
No
If you have answered yes to any of the above, please provide further information here...
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Please answer the following questions
Are you currently taking any prescription medication
*
Yes
No
Do you currently have an infection of any kind? (e.g. cold, flu, tonsillitis)
*
Yes
No
Do you have any current injuries? (e.g. fractures, muscle tears)
*
Yes
No
Within the last year, have you had any operations?
*
Yes
No
Do you have a pacemaker, metal plates, pins or any other artificial device fitted to your body?
*
Yes
No
If you have answered yes to any of the above, please provide further information here...
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FEMALE CLIENTS ONLY
Within the last two weeks, have you given birth?
Yes
No
Are you currently pregnant?
Yes
No
If you have answered yes to any of the above, please provide the following information...
Is your pregnancy stable?
Yes
No
N/A
State of pregnancy
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If you are suffering from any other conditions or disorders that you think may affect your massage treatment, please list them here...
Client Signature
Submit
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