Wellness with Majella Consultation Form [LOGO PLACEHOLDER] Business details: Wellness with Majella Wexford, Ireland Email: hotyogawexford@gmail.com Website: wellnesswithmajella.com ============================================================ PERSONAL INFORMATION ============================================================ Name: ______________________________________ Phone: ______________________ Address: ___________________________________ City: _______________________ Post code: _________________________________ DOB: _________________________ Occupation: ________________________________ Email: _______________________ GP address: ________________________________ GP name: _____________________ Emergency Contact: _________________________ Relationship: ________________ Emergency Phone: ___________________________ How did you hear about us? _________________________________________________ ============================================================ MEDICAL INFORMATION ============================================================ Please indicate any of the following that apply to you: [ ] Cancer [ ] Fibromyalgia [ ] Headaches/Migraines [ ] Stroke [ ] Arthritis [ ] Heart Attack [ ] Diabetes 1 [ ] Kidney Dysfunction [ ] Joint Replacement(s) [ ] Blood Clots [ ] High/Low Blood Pressure [ ] Numbness [ ] Neuropathy [ ] Sprains or Strains If yes, how far along? _____________________________________________________ Are they controlled by medication? _________________________________________ Do you suffer from chronic pain? Yes [ ] No [ ] If yes, please explain: ____________________________________________________ Have you had any recent surgeries? Yes [ ] No [ ] If yes, please list: _______________________________________________________ ============================================================ MASSAGE INFORMATION ============================================================ Have you had a professional massage before? Yes [ ] No [ ] How long ago? ______________________________________________________________ Do you have any allergies or sensitivities? Yes [ ] No [ ] Please explain: ____________________________________________________________ Are there any areas you do not want massaged? Yes [ ] No [ ] Please explain: ____________________________________________________________ ============================================================ CONSENT ============================================================ I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. Client signature: ______________________________________ Date: ___________ Therapist signature: ___________________________________ Date: ___________ Submission timestamp (for digital copy): ____________________________________