Consultation Form

Please fill out this consultation form prior to your first massage with Victoria Massage.

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Phone

Social Media

07375 394 706

hello@victoriamassage.co.uk

Full Name

D.O.B

Phone

Doctors Name & Surgery

Occupation

Do you or have you ever had any of th efollowing: Varicose Veins, Phlebitis, Heart Conditions, Stroke, High/Low blood pressure, Thrombosis, Undiagnosed Lumps, Epilepsy, Diabetes, Haemophilia, Cancer

Do you currently have any of the following: Swelling, cuts/abrasions, Areas of infection, Inflamation, Fever, Vomiting/Diarrhoea, Bruises or Haematomas, Recent Haemorrhages, Metal plates/Pins, Hormonal Implants/Osteoporosis, Arthritis, Rheumatisim, Nail disease, Skin disorders

Have you ever suffered from any of the following: Eczema, Dermatitis, Psoriasis, Acne, Skin cancer, Allergic reactions, Hay fever, Asthma, Nervous condition, Cervical Spondylitis, Bells Palsy, Inflamed nerve, Trapped Nerve, Medical Oedema

Are you currently undergoing treatment fr any condition? If yes please give brief details

Consultation Form

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