Massage / Reflexology Consultation Form with Victoria Rose Name * Email List any medications, supplements, or herbal remedies you currently take: Preferred Massage Pressure? What is your stress level right now? Low Average Somewhat Stressed Very Stressed Please select conditions you are experiencing or have experienced: Cough/cold High blood pressure Low blood pressure Chronic congestive heart failure Heart attack Varicose veins Stroke/CVA Pacemaker or similar device Heart disease Chronic cough Shortness of breath Bronchitis Asthma Emphysema Hepatitis Skin conditions TB HIV History of headaches History of migraines Vision problems Vision loss Ear problems Hearing loss Loss of sensation Diabetes Allergies/hypersensitivity Epilepsy Cancer Arthritis Gynecological conditions Postpartum Neck pain Back pain Bruise easily Seizures Knee/Leg pain Jaw pain / clenching / grinding Metal implants Fibromyalgia Used Retin-A within the past 10 days If you answered YES to any of the above, please provide details below: Is there a chance you could be pregnant? * Yes No N/A Current medications and condition it treats: Are you currently receiving treatment/under investigation from another health care professional?: Recent surgeries: Relevant recent injuries: Do you have any other medical conditions? (eg. digestive conditions, hemophilia, osteoporosis, mental illness)? Do you have any internal pins, wires, artificial joints?: What is your goal for this session?/ What would you like to address? Date * Month Day Year Submit
