Please fill in and submit before your 1st appointment.


Thai Yoga Massage - Health Questionnaire

Name:

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Date of birth:

Profession:

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Phone no:

Are you presently under the care of a medical doctor or health practitioner? YesNo If yes, for what reason(s)?
Are you presently taking medications? YesNo Do they have any side effects?
Do you have any restrictions in movement? Are there any yoga poses or stretches that you fear may be harmful?
Are you pregnant? YesNo If yes, when is your due date?
Do you wear contact lenses? YesNo Is your blood pressure: NormalHighLow
Do you have varicose or thread veins? YesNo Are you diabetic? YesNo
Have you had any accidents in the last 3 months? Have you had surgery in the last 3 months?
Do you suffer from any irregularities of the bowels? How is your sleep?
Are there any areas in your body where you hold tension or feel pain? Do you suffer from pain in your lower back?
Anything else that hasn't been covered?

CONSENT FOR THAI YOGA MASSAGE

I understand that the purpose of Thai Yoga Massage is for relaxation, sports performance enhancement and general wellbeing. Treatments are not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. I have informed Thai Yoga Massage Essex about my state of health and I have transmitted to them any recommendations and restrictions on the part of my medical doctor or physiotherapist accordingly.

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