Livewell | Massage Medical Screening

General Client Details

Name*

Date of Birth*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Number*

Email*

GP Name and Address*

Where did you hear about LiveWell? Have you attended any other LiveWell service in the past?*

Medical Questionnaire

Are you currently experiencing OR ever been diagnosed with any of the following conditions?

*

Lower back pain
Pelvic pain
Any other spinal condition
Any other oprthopaedic conditions
High or low blood pressure
Epilepsy (Grand mal seizures)
Heart problems
Osteoporosis/Osteopenia
NONE OF THE ABOVE

If you ticked any of the above, please provide details of the condition.

If you selected 'none of the above', please mark N/A in space provided.

Are you pregnant?*

Please note pregnancy massage is not currently a service offered at LiveWell. We do offer specialist pregnancy physiotherapy services. If you are booked in for a massage therapy service, it is essential that you contact the clinic to discuss an alternative to a massage appointment if you are currently pregnant.

Have you ever had an episode of Lower back pain?*

If yes, how many previous episodes of Lower back pain have you had?*

Have you had any recent injuries or surgery?*

If yes, please provide details:

Which, if any, of the following conditions have you been diagnosed with or had treatment for:*

If you have checked any of the above conditions, please explain/provide further information*

Are you currently on any medication?*

Please outline any medication you are taking, including full name of medication and dosage.

If you have other health conditions you would like to make known to us, please state them here:

Massage and Lifestyle Information

In order to optimise your massage experience and tailor it to best suit your needs, it is helpful for your therapist to be aware of your massage preferences as well as general lifestyle information. If you do not wish to answer any questions, please leave blank and your therapist will discuss this form with you prior to massage intervention.

Have you had a professional massage before?*

What type of massage are you seeking?*

What pressure do you prefer?*

Do you have any allergies or sensitivities?*

If yes, please provide details.

Are there any areas you do not want massaged?*

For example: Feet, abdomen, face, head. Please explain so that your therapist can discuss with you prior to massage.

What are your goals for this treatment session?*

For example: Stress relief, relief of tension, calming. Please outline for your therapist so that they can discuss prior to your massage.

Please use this information box to share any other information you feel your therapist should know.*

If you have no information to add, mark N/A in the space provided.

Client Informed Consent

Massage therapy involves the application of soft tissue techniques to the body. It is essential that you confirm that you have answered this form to the best of your ability and knowledge. It is your responsibility to inform your therapist if there is any change to your medical information as this may impact your suitability and safety for massage. You must also inform your therapist should you feel unwell at any time during your massage. Clients are advised to hydrate with water following massage and to take sufficient time to get dressed and feel ready to leave their treatment room.

Your comfort is paramount during a massage. The nature of massage is such that you will be required to have body areas exposed. While towels are used to drape and cover body areas to ensure your maximum comfort, It is your responsibility to inform your therapist, at any time, if you should feel uncomfortable or wish to stop the massage. Towels are used to cover body areas at all times. Underwear is always kept on throughout massage appointment. The massage may incorporate lying on your back, tummy or onto each side. It is your responsibility to inform your therapist should you feel uncomfortable in any position or need to change. You also acknowledge that you have disclosed any allergies or skin senstivities in order that the likelihood of any skin/allergic reaction is minimised.

Please note the cancellation policy for therapy appointments as per booking email. LiveWell does enforce a strict cancellation policy. Please also note that full details of company privacy policy, in line with GDPR legislation, can be viewed in reception prior to your therapy appointment or if specifically requested.

THIS INFORMATION IS PROTECTED BY THE DATA PROTECTION ACT 1984.

I have read and agree to terms*

Live Well Waterford

Massage Medical Screening