How did you hear about us?
Medical History Do you suffer or ever suffered from any of the following?
Please give details of any of the above including regular medication you are taking.
Is there anything else about your health and wellbeing you would like to tell us?
I confirm I have no health conditions that would contraindicate massage therapy, assisted stretching, breathwork, or mobility work, and my GP has not advised me to avoid these treatments.
Current Problem Primary areas of concern
Select priority areas (or describe with as much detail below):
Describe in your own words what you are feeling and how it’s affecting your daily life.
How did it start/happen?
What makes it worse?
What makes it better?
Lifesyle Questions These questions help us to understand the close rapport between your lifestyle and the current issue.
What physical activity / sports do you do during the week? And how often?
What's your favourite activity to help you wind down and relax?
Hobbies, what do you like to do?
What brings you to see me, what are your reasons for treatment, what results do you expect?
Declaration and informed consent
I confirm this information is honest, accurate and correct to the best of my knowledge. I consent for treatment to take place and understand that I can withdraw my consent at any time. I understand that massage/bodywork/breathwork is not a substitute for medical care and will inform my therapist of any discomfort.
Data Protection (GDPR-Compliant)
I consent to my personal and health data being stored securely for 7 years as required by UK healthcare guidelines. I understand this information will only be used for treatment purposes and will not be shared without my consent, except where legally required (e.g., safeguarding concerns). I may request access to or deletion of my records at any time.
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