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Body Massage - Consultation Form

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Yes
No
Do you suffer from unstable blood pressure?
Yes
No
Do you suffer from any heart disorders?
Yes
No
Do you suffer from Phlebitis?
Yes
No
Do you have a history of Thrombosis/Embolism?
Yes
No
Do you have Epilepsy?
Yes
No
Do you have a dysfunction of the nervous system?
Yes
No
Do you suffer from any infectious diseases?
Yes
No
Do you suffer from any skin disorders?
Yes
No
Do you have any sever bruising?
Yes
No
Do you have any recent scar tissue?
Yes
No
Have you recently suffered from a haemorrhage?
Yes
No
Do you have any varicose veins?
Yes
No
Do you suffer from any swelling/ oedema?
Yes
No
Do you have any recent cuts or abrasions?
Yes
No
Have you recently had any operations?
Yes
No
Yes
No
Have you recently had any inoculations?
Yes
No
Have you ever had or do you have cancer?
Yes
No
Do you have any recent fractures or sprains?
Yes
No
Do you have diabetes?
Yes
No
Do you have osteoprsis?
Yes
No
Do you suffer from arthritis?
Yes
No
Do you suffer from any back problems?
Yes
No
Do you suffer from any allergies?
Yes
No
Do you have any other medical condition?
Yes
No