NPPCaress

Client Personal Information

Date Of Birth

Habits & Lifestyle

Rate your overall stress level

Medical History

Please tick if you suffer ( or have ever suffered ) from any of the following :

Under Medical

Under Therapeutic Treatment

Bone/Joint issue

Sprain/Soft Tissue

Osteoporosis

Arthritis

Headaches

Sleep disorder

Cancer

Heart Condition

Varicose Veins

Blood clots

High/Low blood pressure

Breathing difficulties

Sinus problem

Hay Fever

Asthma

Allergies

Skin disorder

Constipation

Bloating

Pregnancy

Diabetes

Epilepsy

Lymphatic system

Medical Histrory

If any of the above have been ticked, please give details

Do you currently have any medical condition not listed above?

List any medication, supplements, or vitamins you take regularly:

Have you had recent surgery (in the last 12 months) on the area to be treated?

Do you suffer from pain?

Massage Information

Have you had professional massage before?

What type of massage are you seeking:

What is your goal for this treatment session?

Discomfort Area

Please indicate where you have areas of discomfort on the picture

Confirmattion

By signing below, you agree to the following. I acknowledge that I am aware of the benefits and risks of massage therapy, and 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.

2026-04-22

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Confirmattion

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