Forge Personal Training — Massage Consultation

Personal Details

Tell us a little about yourself.

First Name *

Surname *

Address *

Phone *

Email *

Date of Birth * You can type your date of birth (dd/mm/yyyy) or choose it from the calendar.

GP name & surgery

Emergency contact name

Emergency contact phone

Relationship to you

Medical History — please tick any that apply:

Help your therapist provide safe treatment.

Medications & Allergies

Current medications (including dosage if known)

Allergies — please list all known allergies

Lifestyle

Occupation

How often do you exercise?

Typical daily water intake

Treatment Information

Areas of tension or discomfort

Pain scale (1 = no pain, 10 = worst pain) Please enter a number from 1 to 10

Previous massage experience

Anything else we should know before treatment?

Pain areas

Where are you experiencing pain or discomfort?

Tap any area of the body where you feel pain or discomfort.

Front

Back

Left side

Right side

Treatment Consent

Data Protection (UK GDPR)

How did you hear about us?

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

Client Signature *

Please sign below.

Date *

Massage Consultation