Medical Declaration Form | Sarah's Health & Beauty

To book an appointment, please call Sarah on 07854 002643

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Medical Declaration

Before attending a massage with Sarah's Health and Beauty, you must complete a Medical Declaration form.

You can download and complete the form by clicking here. Please print the form and bring it along with you to your appointment.

Alternatively, you can complete the online form below. Once submitted, the form will be securely stored by Sarah's Health and Beauty, and only accessed before or during your treatments by Sarah.

Patient Intake Form (#3)

Personal Information

First Name

Last Name

Patient Age

Patient Gender

Phone no.

Address

Address Line 1

Address Line 2

City

County

Post Code

Occupation

Primary Physician

Emergency Contact

Your relationship with Emergency Contact

Emergency Contact No :

How did you hear about us?

Medical Information

Please provide as much detail as possible.

Are you taking any medication?

Yes

If yes, please list your medication

Are you currently pregnant?

Yes

If yes, how long have you been pregnant?

If pregnant, do you have any high risk factors?

Do you suffer from chronic pain?

Yes

If yes, please explain

What helps alleviate your pain?

What makes your pain worse?

Have you had any orthopedic injuries?

Please tick all that apply to you :

Cancer

Headaches / Migraines

Arthritis

Diabetes

Joint Replacement

High / Low blood pressure

Neuropathy

Firbomyalgia

Stroke

Heart Attack

Kidney Dysfunction

Blood Clots

Numbness

Sprains or Strains

Massage Information

Have you had a professional massage before?

Yes

What type of massage are you looking for?

Relaxation

Therapeutic / Deep Tissue

What pressure do you prefer?

Light

Medium

Deep

Do you have any allergies or sensitivities?

Yes

If yes, please explain

Are there any areas (feet/head/abdomen) that you do not want massaged?

What are your goals for this treatment?

Please list any areas of discomfort

Please type your name in BLOCK CAPITALS to act as your signature

Enter the date you completed this form

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Important Pages

Sarah's Health and Beauty specialise in Sports and Deep Tissue Massage, as well as Swedish and Pregnancy Massage.

We also offer a range of Beauty Treatments.

With over 16 years in the industry you can be sure of a warm welcome and a professional service.