INDIAN HEAD MASSAGE CONSULTATION FORM
Client note
The following information is required for your safety and to benefit your health. While Indian head massage is a very safe treatment, there are certain contraindications that may require special care. The following information will be treated in the strictest of confidence. It may, however, be necessary for you to consult your GP before any treatment can be given.
Date of initial consultation: ______Client ref. no.: ______
Personal details
Name: ______Title: Mr/Mrs/Miss/Ms/other______
Address:______
______
Telephone number (daytime): ______(evening):______
(mobile): ______Email address: ______
Date of birth: ______Occupation: ______
Medical details
Name of doctor: ______Surgery: ______
Address:______
Telephone number: ______
Do you have/have you ever suffered with any of the following?
(Please give dates and details)
Dates and details
Recent head or neck injury?YN______
Cardiovascular condition?YN______
Thrombosis or embolism?YN______
High or low blood pressure?YN______
Dysfunction of the nervous system?YN______
Cancer/chemotherapy or radiotherapyYN______
Recent haemorrhage?YN______
Cuts or abrasions in the treatment area?YN______
Recent operation?YN______
Diabetes?YN______
Epilepsy?YN______
Spastic conditions?YN______
Migraine/severe headaches?YN______
Skin/scalp or hair disorder or infection?YN______
Recent scar tissue/bruises/open cuts/large moles
lumps/other swellings?YN______
Any allergies?YN______
Any medical condition (not mentioned above)?YN______
Are you currently under the influence of drugs or
alcohol?YN______
Current medical treatment:______
Current medication (list dosages): ______
GP referral required:Yes ( )No ( )
General state of health
Do you smoke?Yes ( ) average per day ______No ( )
Do you drink alcohol?Yes ( ) average consumption ______daily/weeklyNo ( )
How many glasses of water do you drink daily? ______
How would you describe your diet?______
How would you describe your skin condition? Normal ( )Dry ( ) Oily ( )
Combination ( ) Sensitive ( ) Mature ( )
How would you describe your posture? Good ( ) Average ( ) Poor ( )
How would you describe your muscle tone? Good ( ) Average ( ) Poor ( )
What are your height and weight?Height ______Weight ______
How would you describe your stress levels?High ( ) Medium ( ) Low ( )
How would you describe your sleep patterns?Good ( ) Average ( ) Poor ( )
Exercise undertaken/lifestyle: ______
______
Do you follow a regular exercise programme?Yes ( )No ( ) Details:______
______
Do you have any hobbies/time set aside for relaxation (give details):______
______
Have you had an Indian head massage treatment before:Yes ( )No ( )
If yes please give brief details of previous treatments and success: ______
______
Are you currently having any other forms of alternative/complementary treatment? (Please give details.)______
______
Client declaration
I declare that the information I have given is true and correct and that, as far as I am aware, I can undertake treatment with this establishment without any adverse effects. I have been fully informed about contraindications and am therefore willing to proceed.