Seated Massage Screening form

Sessions are 20 minutes in duration.

Name*
Email address
Occupation
Contact number
Have you had a seated massage before?
Are you under a chiro/physio/osteo currently? If so give details.
Are you experiencing any of the following? Please check necessary boxes
- Headaches
- Neck pain
- Upper back pain
- Shoulder pain
- Teeth grinding
- Seizures
- High blood pressure
- Low blood pressure
- Diabetes
- Numbness or tingling upper limb
- Herniated disk anywhere in neck or back
- Fractures
- Hypertension
- Epilepsy
- Nausea
- Dementia
- Bruise easily
- Heart conditions
- Cancer
- Recent surgeries
Are you pregnant?
If yes please make your therapist aware.
Areas of focus during your appointment for today? Please note below.
By typing your name below you agree that you have provided the correct information above.