Home
Our treatment
Gallery
Contact
Questionnaire
PROVIDE THAI MASSAGE
PROVIDE THAI MASSAGE
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
would Consent day
MEDICAL HISTORY (TICK BOX IF APPLICABLE)
Diabetes
Recent Surgery
Raised Varicose veins
Recent fractures
Condition affecting the neck (e.g. Whiplash)
Hernia
Faver
Any Allergies
Metal Plate
Asthma
Osteoporosis
Trapped nerve (e.g. Sciatica)
Medical Oedema /Swollen Glands
Heart Conition /Pacemaker
Scar tissue (6 months-2years)
Bell’s palsy /Neuritis
Stress /Anxiety /Depression
Hormonal implants /Stents
High /Low Blood Pressure
Infectious diseases /Flu
Sprain /Strain
Cuts /bruises /abrasions
Haemophilia
Arthritis /Acute Rheumatism
Chronic fatigue syndrome /Fibromyalgia
Diarrhoeas or vomiting
Cancer
Menstruating /Pregnancy
Epilepsy
Any others
Contagious Skin diseases (e.g. Verruca)
Haemorrhages
Clients (Written & Informed) Consent Statement
*
I agree to act as a model and receive a Thai Massage treatment.
I confirm that the information I have provided regarding my medical history is accurate.
Client’s signature (Name)
*
1. What is your occupation?
*
2. Do you have an active or a sedentary lifestyle?
*
3. What is your fluid intake a day?
*
4. Do you drink alcohol?
*
Yes
No
how many units per day
5. Do you smoke?
*
Yes
No
how many a day
6. Do you have children?
*
Yes
No
How would you describe your diet?
*
Healthy
Balanced
Poor
How would you describe your sleeping pattern?
*
Good
Fair
Poor
How would you describe your stress level? (Low)1-2-3-4-5-6-7-8-9-10 (High)
Selected Value:
1
Submit
