Anamnese massage Anamnesis massage/body ENPersonal dataDate first intake Last name First name Address Postal code City Phone number Email Date of birth Nationality Gender Maak een keuzeMenWomanMedical data Do you have one of the following conditions? AsthmaArthritisRespiratory problemsBone fractures / bruisesDiabetesEpilepsyFibromyalgiaCardiovascular diseasesCancerFeverMigraine / headacheOsteoporosisPsychological problemsBack problemsRheumatismSkin conditionHerniaNeck and shoulder painHigh blood pressure / low blood pressureVaricose veinsDo you use medication? For which conditions? Do you use vitamins or nutritional supplements? Which and for what? Have you ever had a serious illness? Which illness and when? Have you ever had surgery? Why and when? Are you being treated by a specialist (physician, doctor, physiotherapist, psychologist etc.)? Do you have allergies? (Massage oils, creams, lotions, perfumes) Do you have a sensitive skin? Are there other important things related to your health that your massage therapist should know? PregnancyAre you pregnant right now? Yes (then please fill in the questions below)No (please skip to the next part)In which trimester are you now? First trimesterSecond trimesterThird trimesterThis is your First pregnancy Second pregnancy Third pregnancy Fourth (or more) pregnancyHow many kids do you have? 1234 or moreIs it a high-risk pregnancy? Yes NoLifestyleWhat kind of job do you have? SittingStandingLight physical laborHeavy physical laborHow many hours per week do you work? Do you exercise often? Daily Multiple times a week Couple of times per month Couple of times per year Almost neverWhat sports do you play? How would you describe your eating habits? Very good Good Not that good BadDrinking alcohol? Never Rarely Now and then A lotDrinking coffee? Never Rarely Now and then A lotSmoking? Never Rarely Now and then A lotStress Never Rarely Now and then A lotAdditional information/remarks about your lifestyle: YOUR EXPECTATIONS FROM THIS MASSAGE THERAPYWhat is your goal or what do you expect from this massage? Have you had massages before? If yes, what kind? Why and how often? Are you feeling any pain or discomfort now? Where? And for how long already? Type in where you feel pain or discomfort or where you would like to focus on during the massage? How often do you experience this pain or discomfort? All the time Now and then Only during certain movementsAre there body parts that we shouldn’t massage? Additional notes/information When you cancel a massage, the following cancellation policy applies: When you cancel up to 48 hours before the start of the massage, you do not owe any cancellation fees. When you cancel 24 hours before the start of the massage, 50% of the treatment price will be charged to you. When you cancel less than 24 hours before the start of the massage, 100% of the treatment price will be charged to you. AGREEMENT MASSAGE THERAPIST – CLIENT By signing this form, I declare I have read, understood, and truthfully filled in all questions. I will communicate any changes in the meantime to the massage therapist immediately. I understand that the purpose of this massage therapy is relaxation and the reduction of muscle tension only. It does not substitute a medical examination or medical diagnosis. I will let the massage therapist know immediately if I experience pain or discomfort during the treatment. By signing this form, I also agree to the stated cancellation policy. I am aware of the nature and expected results of the proposed treatment. I have read that there are certain guidelines before and after treatments to achieve optimal results. I have informed the practitioner of my conditions, medication use and any hypersensitivities. I know that complications can occur and if I suspect that to be the case, I will contact them. I understand that no guarantees can be made about the outcome of treatment. I have received, understood and agree to the above information, statement and client advice both verbally and in writing. I am undergoing the treatment of my own free will and take responsibility for it.Submit
