Massage Consultation Form Full name Date of birth Adress Mobile number Occupation Email I would like to receive the information in the future regarding any promotions yes no Which part of your body is uncomfortable? ‘0’ being ‘no pain’ and ‘10’ being the ‘worst possible pain’. E.G. Left shouder 5/10What symptoms or sensations are you feeling in the mentioned area?（sore/ stiff / pain /numbness/tingling/cramping）I would like to have Therapeutic Massage Relaxation Massage Foot Reflexology Whole body Massage I would like to have regular massages if they are beneficial to me. I have insurance (E.G. Southern Cross) Desired Pressure Deep Moderate Soft Do you hold ACC claim number for any injury within 1 year Yes No The ACC Number& when was it happened?Time&Session 30mins 45mins 60mins 90mins 120mins 3 sessions concession card Please check the box if you have any of the following symptoms. Contagious disease (E.g. Hepatitis, TB, Flu, HIV, etc) I’m pregnant ankle,wrist or shoulder limitation of movement arthritis tennis elbow Heart disease Digestive issue（pain,bloating,constipation,diarrhea,gas） Tinnitus Hay Fever High Blood pressure Asthma cancer Diabetes Cold limbs or feet Sinus problem/Hay Fever Dizziness Varicose Veins Sweat easily(hand/foot,back,head) Eczema Acne Angry Depression Anxiety Insomnia PMS Menopause syndrome Period pain Excessive Dreaming Thyroid issues Frequent urination Infertility I'm open mind to try for the above symptoms if it's helpful. cupping physio herbal supplement Attention: Our website will not store any of your personal information. After completing the form, please click on the 'submit’ button and send the PDF document via email, or take a photo and send it to your therapist.
