Thank you for booking in to see me. I look forward to helping you with your health.
Please answer the following questions with as much detail as possible.
Your name:
Contact number:
Your email address:
Your address:
Is it ok for me to add your email to my mailing list so I can keep you up to date with my news and offers? (max. 1 email per month!)
Please follow the link and read my Privacy information - and then tick the box to accept the way I work.
How can I help you? Why did you decide to come and see me?
Are you currently receiving any treatment from another practitioner? If so, please give details.
Please list any medication, remedies or supplements you are currently taking or often take:
Please give details of any surgery, hospitalisation, major illness or trauma (accidents, broken bones, etc):
Please give details of any pain you regularly experience:
Please describe your digestion:
Do you have (or have you had) any of the following? (please tick all that apply)
Do you have any other health conditions?
Are you or might you be pregnant?
What work do you do?
Do you have any recent (last 3 months) lumps, bumps, bruises or scars?
What hobbies or physical activities do you enjoy?
Do you have any known allergies?
Is there anything else which you think may be relevant?
How did you hear about me?
I confirm that the information I have given in this form is complete and accurate and I hereby consent to receiving Massage from Jane Collison.
Thank you for completing this questionnaire.
Please note: your skin will be coated with deliciously aromatic and moisturising natural oils following your massage - this may transfer to clothing and hair.
I look forward to meeting you and helping you with your health!
Best wishes
Jane
Privacy & Confidentiality: the information in this form is collected by me so that I can provide individual, safe and effective care to you. I keep paper client records for a statutory 7 years. They include a print out of this form (which is never saved on a computer). If you would like to see your records at any time, please ask. As a result of this form, I will add your email address to my mailing list unless you tell me you do NOT wish to receive emails from me - you can do this now or at any time in the future. I will never, ever share your details or any personal information about you with anyone else (unless you have given me permission to speak to another therapist to whom I refer you). I am a Professional member of the Association of Systematic Kinesiology and bound by their code of ethics. I am professionally insured to practise Massage and Aromatherapy by Balens.
