Medical Form - Kat Kornblum Holistic Massage

Medical Questionnaire

If you have booked a treatment with me, either privately or with Equilibrium Clinic then on your first visit you will need to fill out the following medical form. If you answer 'yes' to any of the questions I may not be able to treat you, so if you are unsure please feel free to contact me.

This form is private and confidential and for our records only. Fill it out online, print off and bring it in with you to save time and make sure you get the full treatment time you have booked. These details cannot be submitted online, they must be printed and signed

Medical Form

Are you currently receiving any form of medical treatment? If yes please fill in details below.	Yes No
Do you have any back or neck problems that should be avoided by massage? If yes please fill in details below.	Yes No
Do you have any allergies or skin sensitivity, including any open wounds? If yes please fill in details below.	Yes No
Are you pregnant? (if yes how many weeks?) If under 12 weeks I do not advise body treatments.	Yes No
Are you currently on medication that affects you having treatments? If yes please fill in details below.	Yes No
Have you had any recent operation? If If yes please fill in details below.	Yes No
Any innoculations within the last 36 hours?	Yes No
Do you have any of the following? (please tick):
High / Low Blood Pressure
Heart Condition
Arthritis / Rheumatism
Circulatory Disorders
Epilepsy
Diabetes
Please use this space to add additional information we may need to know:

Signature:
Print name:
Date:

Kat Kornblum Holistic Massage Therapist ba dip (itec)

Medical Questionnaire