Welcome to Anna's Holistic Centre
Holistic Massage Consultation Form
Please take a moment to carefully read the following information and sign were indicated. If you have any specific medical condition or specific symptoms, massage/body work, may be contraindicated. A referral from your primary care provider may be required prior to service being provided. Thank You.
Name:
*
Address:
*
Telephone:
*
Email Address:
*
Date of birth:
*
Sex:
*
male
female
How did you heard about me?
*
Occupation-(this will help me to understand what kind of stress if any you might have at work)
*
Do you suffer from any of the following?(tick if yes)
*
serious heart condition or circulatory disorder
recent stroke, haemorrhage or blood clots
scalp infection (nice, lice etc.)
any infectious conditions and/or disease
high temperature or fever
Pregnancy (1st trimester) or suspected pregnancy
problems with (or under the influence of) drugs or alcohol
diarrhoea and /or vomiting
Thrombosis, phlebitis, hypertension, hypo-tension
Haemophilia or medical oedema
recent injury, operation or surgery anywhere
osteoporosis/spondytlitis/rheumatoid or osteo-arthritis
Epilepsy, asthma or diabetes
Undiagnosed lumps, bumps or swellings
Recent severe, undiagnosed headaches, lumps or bumps
Paranoia, psychosis or shizophrenia
very high or low blood pressure
Cancer (active or in remission)
Central nervous disorders, cerebral palsy, multiple sclerosis and or Parkinsonism
History of musculo-sleletal problems
Fractures/ sprains on body
Nervous system disorders
Trapped, pinched or inflamed nerve
Recent scar tissue on body
kidney infection
slipped or herniated disc
Sunburned, hypersensitive, cut, brusied or broken skin
severe allergies
Localised swelling, inflammation or varicose veins
Any conditions you think might affect treatment (details on reverse)
General health/immunity
*
Good
Averadge
Poor
Stress Levels
*
High
Medium
Low
Energy Levels
*
High
Medium
Low
Do you find time to relax and hobbies
*
Often
Sometimes
Never
Terms and conditions:
*
I give my consent for the treatment and conform that all of the information I have given are correct. I understand that complementary therapist does not diagnose and does not prescribe any medical treatments or medication. The Holistic Massage is not to be used as a substitute for medical examination or diagnosis and it's recommended that I see a physician for any aliments that I might have. I do understand that an Holistic Massage is combined with an Energy Healing and it work on a deep energetic level and sometimes after session I might feel a bit tired or an old emotional issue can come up to a surface for them to be dealt with it. I will come to a session with an open mind and will follow an additional exercises and tools to help me with a self healing process. I will treat Anna Bojaryn with a respect and won't misbehave in any way, or will make her feel uncomfortable. In any case of any kind of abuse or harassment I do understand that Anna Bojaryn has a right to stop a session and inform a higher authorities.
In a case of a cancellation for a session in person I will give a minimum of a 24(and 48 in distance healing) hours notice. Late (less than 24(and 48 in distance healing) hours, cancellation fee- is charged for the full amount of the treatment price. I understand my details will be kept safe and will not, at any point before, during or after treatment, be shared with a 3rd party. GDPR act from 2018.
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