Treatment Consultation Form

suzana@bodyworkplus.co.uk

About
Services

Book a Session

(+44) 07535 482227

suzana@bodyworkplus.co.uk

About
Services

Book a Session

(+44) 07535 482227

About
Services

Treatment Consultation Form

		The information provided in this form is used solely to help Suzana deliver a safe and suitable treatment experience. 
Your information will be handled confidentially and stored securely.		
	

Treatment Consultation Form

First Name

Last Name

Date of birth

Have you booked a massage therapy treatment?

Yes

Do you have any medical conditions?

Yes

Please provide details

Are you currently taking any medication?

Yes

Please specify

Please confirm you are not on any blood thinning medication.

I confirm I'm not on any blood thinning medication.

Do you have any allergies?

Yes

Please specify

Have you had any recent injuries or surgeries we should be aware of?

Yes

Please provide details

Please list main complaint

What is the main reason for your massage appointment?

Have you booked a treatment including dry needling?

Yes

Have you previously received dry needling?

Yes

Do you have any history of blood disorders (blood clotting disorders, hepatitis, haemophilia)?

Yes

Please provide details

Do you have any medical conditions?

Yes

Please provide details

Are you currently taking any medication?

Yes

Please provide details

Please confirm you are not on any blood thinning medication.

I confirm I'm not on any blood thinning medication.

Do you have any allergies, skin sensitivities, or metal allergies?

Yes

Please provide details

Have you had any recent injuries or surgeries we should be aware of?

Yes

Please provide details

What is the main reason for your dry needling appointment?

Book a Session

(+44) 07535 482227

Book a Session

(+44) 07535 482227

Treatment Consultation Form

Professional bodywork, delivered to your home