Health Declaration - DS Holistic Massage Therapist

Full Name *

Gender *

Email *

Phone Number *

Date Of Birth *

Country of Residence *

Medical History

Please choose the appropriate answer if you are currently suffering from any of the following

Asthma *YesNo

Cancer *YesNo

Do you have any other condition not listed that could affect your treatment options, such as slow healing, bruising, sensitivity to cosmetic ingredients etc?

Have you had any surgery in last three year? If yes, please state

Are you currently taking medication? If yes, please state

Any additional comments you may want to add?

Only for Ladies

Are you Pregnant? If yes, how far along

Are you currently menstruating?

I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. DS Holistic Therapist will not be liable for contra-indications to treatments due to medical information withheld or for any personal valuables, belongings that are brought into the studio.

Signature *Type your full name

I declare that the info I’ve provided is accurate and complete