Massage Pre-Therapy Questionnaire

Name*
First Last
Date of Birth:*
DD slash MM slash YYYY
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email*
Phone Number (ideally mobile)
Emergency name and contact:*
Doctor:*
Surgery number:
Do you currently or have you ever suffered any of the following conditions? Please tick YES or NO
Do you have high blood pressure?*
- Yes
- No
Do you have low blood pressure?
- Yes
- No
Have you recently had surgery?
- Yes
- No
Has your doctor ever said that you have a heart condition?
- Yes
- No
Do you have Thrombosis?
- Yes
- No
Do you have Diabetes Mellitus or any other metabolic disease?
- Yes
- No
Do you suffer from seizures?
- Yes
- No
Do you have varicose veins?
- Yes
- No
Do you have Sinusitis?
- Yes
- No
Do you have Cancer?
- Yes
- No
Do you have Haemophilia?
- Yes
- No
Do you have Systemic Oedema?
- Yes
- No
Is your doctor currently prescribing you drugs or medication?
- Yes
- No
Do you often feel faint, have spells of severe dizziness or have lost consciousness?
- Yes
- No
Have you ever suffered from unusual shortness of breath or chest pain at rest or with mild exertion?
- Yes
- No
Please give more details where necessary on any of the above points:
Do you have any skin conditions I need to know about? Please state any below, such as Lice and Mites, Herpes Simplex, Athletes Foot, Ringworm, Warts/ Verrucae, Severe Eczema, Psoriasis, Dermatitis, Severe Acne/ Boils, Impetigo or Allergies? Please state any below.
Do you have any injuries such as Burns, Severe Bruising, Open cuts/ wounds, Fractures? Please state any below.
Do you currently have a virus or infection? For example (but not limited to) Glandular Fever, TB, Lymphangitis, HIV/AIDS, Pneumonia, a fever, Shingles? Please state any below.
Do you have any joint problems such as Acute Sprain/ Strains, Bursitis, Osteoarthritis? Please state any below.
Please give details of any recent or old injuries, surgeries or scars, even if it dates from childhood:
If you have had any recent treatment or surgeries, are you still under consultant care? Please provide Consulant details (name, hospital, contact if possible) if not provided above under your doctor details.
If you have a scar and would like ScarWork treatment, please give more details here. Do you have numbness or sensitivity? Are you aware of any pulling or restriction to movement? Are you aware of any mesh?
Please fill out this section if you are having a pregnancy massage.
Due Date/ Number of Weeks Pregnant:
Last visit to Primary Health Provider and outcome? Multiple pregnancy?Scan results? Do you have your antenatal notes? If so please bring them.
Do you currently or have you ever suffered any of the following conditions?
- Symphysis Pubis Dysfunction (pain in the central pubic area)
- Carpal Tunnel Syndrome (Wrist/finger/hand forearm pain/numbness or tingling)
- Upper Back/Neck/Shoulder Pain
- Lack of total Bladder/Bowel Control (Urinary or Feacal Incontinence)
- Piles/Haemorrhoids/Varicose Veins/ Constipation
- Has anyone said you have Placenta Previa?
- Do you have an incompetent cervix or cerclage?
- Do you have a history of miscarriages?
- Any spotting or blood loss at any level?
- Do you have intrauterine growth restriction in your current pregnancy?
- Have you had rapid or large weight gain while pregnant?
- Any severe and chronic itching?
- Any headaches or dizziness?
- Any amniotic fluid leakage?
- Any history of blood clots or thrombosis? Any calf pain, swelling or redness?
- Any excessive thirst or urination?
- Any excessive or sudden swelling and water retention?
- Any regular or painful contractions?
- Do you feel dizzy or light headed when you lay on your back?
Please give more details where necessary on any of the above points:
Please fill out this section if you are having a postnatal massage. Even if you are pregnant or having a sports massage, if you have had a baby before this information is useful
Date of Delivery:
DD slash MM slash YYYY
Number of children:
Type of Delivery, including position if vaginal (Assisted, Vaginal, C-Section, episiotomy, tear):
6-8 Week Check-Up Date & Outcome:
Post Natal Bleeding Status:
Please give details of your Pregnancy & Post Natal, include any complications, illnesses, reasons to visit your Doctor or any other Health Practitioner including Massage, Acupuncture, Pilates, Physiotherapy, Osteopathy, Chiropractor etc.
Do you currently or have you ever suffered any of the following conditions?
- Symphysis Pubis Dysfunction (pain in the central pubic area)
- Carpal Tunnel Syndrome (Wrist/finger/hand forearm pain/numbness or tingling)
- Upper Back/Neck/Shoulder Pain
- Lack of total Bladder/Bowel Control (Urinary or Feacal Incontinence)
- Piles/Haemorrhoids/Varicose Veins/ Constipation
- After Effects of Gestational Diabetes
- Joint Pain
- Vaginal Disorder
- Vaginal Bleeding
- Sacrum or Sacroiliac Joint Pain (pain in the very low mid back – top of buttocks)
- Knee Pain (Side/front)
- Coccyx Damage or Pain
- Prolapse (Uterine, Bladder, Rectum, Vaginal)
- Were you given an Epidural during birthing?
- C-Section wound discomfort or slow healing or ongoing numbness
- Buttock/Piriformis Pain/Sciatica
- Incomplete cervix
- Acid Reflux?
- Bleeding during or after exercise or any unexplained bleeding
- Rib Pain or Expansion During Pregnancy?
- Diastasis (Separation of your abdominal muscles)
- Breast Health/Breast Feeding Issues
- Nerve Damage During Birthing (Especially Pudendal)
- Anaemia or taking Iron medication
- Episiotomy Cut, Painful Perineum or Tears (Degree if known)
- Pelvic/ abdominal cramps
- Thrush (recently) or any Bowel/ Gut Issues?
Please give more details where necessary on any of the above points:
Client's Name:*
First Last
Assumption of Risk and Informed Consent I confirm that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities which may include resistance exercise (to strengthen muscles that may be weakened and contributing to aches), stretching, and release or massage work using a foam roller, instrument assisted massage, or massage therapy, including ScarWork. I realise that my participation in these activities involves the risk of injury and even the possibility of death. If at any time I feel any pain or discomfort, I will inform the therapist, Vanessa Barker. Likewise, if I feel that I should not do a particular exercise or massage for any reason I understand that I must inform the therapist. I agree to seek medical advice and treatment for any conditions indicated on this form (any question I have answered Yes to), such as pelvic organ prolapse, incontinence, pelvis and back pain, as Vanessa Barker cannot treat these. I will consult my Doctor before treatment is given where necessary. Furthermore, I hereby confirm that I am voluntarily engaging massage therapy and that my therapist will need to be informed of any changes in my condition. It is further expressly agreed that all resistance training, or any other exercise shall be undertaken by me at my sole risk and that Vanessa Barker shall not be liable to me for claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located. Each part of the massage/activity/exercise you participate in will be fully explained, and you are strongly advised to ask questions if you are not clear about anything. Any information provided by Vanessa Barker is not intended to be a substitute for professional medical advice from a doctor, nutritionist or dietician. You must not rely on this information as an alternative to medical advice, and Vanessa Barker expressly disclaims all responsibility and liability for any damages, loss or injury suffered by you or any third party as a result of this information. Training includes general nutrition advice, and as with all dietary programmes, you must get your physician’s approval prior to making any changes to your diet, for diagnosis and treatment of illnesses, and for advice regarding medications. Nothing provided is intended as medical advice and is not intended to replace the advice or attention of health‐care professionals. Always consult your physician before beginning or making any changes in your diet and/or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications. This is not a medical treatment and I am not receiving the treatment from Vanessa Barker in any medical capacity. No diagnosis has been given.*
Assumption of Risk and Informed Consent

I confirm that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities which may include resistance exercise (to strengthen muscles that may be weakened and contributing to aches), stretching, and release or massage work using a foam roller, instrument assisted massage, or massage therapy, including ScarWork. I realise that my participation in these activities involves the risk of injury and even the possibility of death. If at any time I feel any pain or discomfort, I will inform the therapist, Vanessa Barker. Likewise, if I feel that I should not do a particular exercise or massage for any reason I understand that I must inform the therapist.

I agree to seek medical advice and treatment for any conditions indicated on this form (any question I have answered Yes to), such as pelvic organ prolapse, incontinence, pelvis and back pain, as Vanessa Barker cannot treat these. I will consult my Doctor before treatment is given where necessary. Furthermore, I hereby confirm that I am voluntarily engaging massage therapy and that my therapist will need to be informed of any changes in my condition. It is further expressly agreed that all resistance training, or any other exercise shall be undertaken by me at my sole risk and that Vanessa Barker shall not be liable to me for claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connected with the use by me of the services provided and of the premises where the same is located.

Each part of the massage/activity/exercise you participate in will be fully explained, and you are strongly advised to ask questions if you are not clear about anything.

Any information provided by Vanessa Barker is not intended to be a substitute for professional medical advice from a doctor, nutritionist or dietician. You must not rely on this information as an alternative to medical advice, and Vanessa Barker expressly disclaims all responsibility and liability for any damages, loss or injury suffered by you or any third party as a result of this information.

Training includes general nutrition advice, and as with all dietary programmes, you must get your physician’s approval prior to making any changes to your diet, for diagnosis and treatment of illnesses, and for advice regarding medications. Nothing provided is intended as medical advice and is not intended to replace the advice or attention of health‐care professionals. Always consult your physician before beginning or making any changes in your diet and/or exercise program, for diagnosis and treatment of illness and injuries, and for advice regarding medications.

This is not a medical treatment and I am not receiving the treatment from Vanessa Barker in any medical capacity. No diagnosis has been given.
- I have read and understood the above assumtion of risk statment and agree to everything contained within.
*
- I confirm that I have acted or will act on any issues arising from the questions on this form and have obtained the medical advice where required (as indicated on the form).
*
- I understand that I am free to withdraw my consent and to withdraw from the activities at any time, without negative consequences.
- I consent to the use of visual images (photos, videos etc.) involving my participation in the activities. This will be for use in my marketing, but I will check with you before taking and sharing any photos. You do not have to tick this box if you do not consent to this.
Use of Data Collected and Privacy Policy.*
Once you submit this data it is kept on a secure website until I download it, at which point I delete the online copy.

I will keep a password encrypted PDF copy on my laptop (password protected and protected by McAfee LiveSafe) and on a password encrypted KnowHow Cloud Storage as back up.

This information is for me to ascertain whether training/massage is suitable, if so what adaptations I may need to take into account, and whether I need to refer you to a Health Care Provider such as your GP or a Physio. The only circumstances under which I will share any information is if you do indeed see another professional, and give me permission to send them details about why I have referred you, including what training I hope to do with you, so as to get their advice on how to proceed.

I will have a hard copy of some information to bring to our sessions. Session notes have your name, DOB, address and phone number at top. These are kept in a locked filing cabinet.

I will keep this information, as well as records of any sessions we have, until 7 years after you cease training with me, as this is the length of time my insurance requires I keep them, in keeping with The Statute of Limitation in the UK. At the end of this period, or if you have completed this questionnaire but do not subsequently train with me I will delete all data, and use McAfee to shred deleted files. I will shred the hard copies of session notes.

If you would like a copy of the PDF I have please let me know and I will send you all the information I have.

With regards to communication, I am not currently using an email encryption programme. Any emails we send to each other may be vulnerable to viruses or human error. If you send me an email, this can be seen on my personal phone which is password protected. Most emails and text messages will be deleted once they have been read/actioned. However it may be necessary for me to keep some messages if they are relevant to your treatment.
- I understand that the information obtained in this personal fitness training programme will be treated as confidential and will consequently not be released or revealed to any person without my express written consent.
*
- I understand I have the right to have personal data rectified if it is inaccurate or out of date, and will inform Vanessa Barker of necessary changes.
*
- I understand I may request in writing a copy of any of my personal data Vanessa Barker has stored.
Date*
DD slash MM slash YYYY
Client’s signature:
Date
DD slash MM slash YYYY
Pelvic Floor Dysfunction Questionnaire
This may seem personal, and even irrelevant to you: if so, that’s great. However over 50% of women suffer continence issues after having children, and in fact, many who haven’t had children do too. This is a sign of a weakness in the pelvic and core area, and if not addressed it can cause worse problems in the future, such as prolapse. And again, 50% of women suffer some form of prolapse after having children, so it is important you’re honest so we can discuss and address any problem. Pelvic Floor Dysfunction (PFD) may present via a wide variety of symptoms and in order to help us to help you understand why your Pelvic Floor isn’t working as well as it used to, you’ll need to answer the following questions as fully as possible. The answers to the following questions will give us both a clearer idea of how to move forward and get you back to great core and Pelvic Health.
Are you experiencing difficulty with your bowel, wind or urinary urges?
- Yes
- No
If yes, please state which.
Do you lose urinary control when laughing, sneezing, coughing or jumping or moving quickly?
- Yes
- No
Do you struggle to 'let go' and begin a stream of urine or bowel movement?
- Yes
- No
Are your bowel movements or urination painful?
- Yes
- No
If YES, please give further details:
Do you experience a sensation of pressure in your vagina or rectum or noticed any protrusions from your orifices? Has anyone ever said you may have a prolapse?
- Yes
- No
If YES, please give further details:
Do you experience pain with intercourse or sexual stimulation?
- Yes
- No
If YES, please give further details:
Do you experience pain in your genitals with or without sexual intercourse?
- Yes
- No
If YES, please give further details:
Do you experience pain inside or at the joints of your pelvis?
- Yes
- No
If YES, please give further details:
Have you ever undergone any gynaecological surgery (eg.,a hysterectomy, fibroids removal?)
- Yes
- No
Do you have a history of low back pain or any other type of back pain?
- Yes
- No
Have you ever sustained an injury to your pelvic region (fracture, radiotherapy or injury to your coccyx?)
- Yes
- No
Do you suffer from constipation or regularly strain on the toilet? Do you need to assist your own voiding?
- Yes
- No
Do you or have you ever had a chronic cough or a condition that affected your breathing (smoking, hayfever, asthma?)
- Yes
- No
Are you or have you been overweight?
- Yes
- No
Do you frequently lift heavy weights? (Gym, work, children, caring for disabled or elders?)
- Yes
- No
Are you incontinent overnight?
- Yes
- No
What is the problem – in your own words?
How many times/ how frequently do you urinate during the day?
How long have you been aware of or concerned by a change in your continence and Pelvic Floor function? Please detail any previous attempts to improve your continence.
What liquids to you drink during the course of your day and how much of each type?
Cancellation Policy*
Payment must be made in advance, and 48 hours notice of cancellation is required for all appointments. Any less will incur full payment of the session fee, although if I can fill the slot I will, and will waive the fee at my discretion.
If you are late the session will not be extended, if the therapist is late time will be added to the appoiintment or later appointments, or a partial refund given. If you are late the session will not be extended. If I am late additional time will be added to the session or later sessions.
- I understand and agree to the cancellation policy

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Massage Pre-Therapy Questionnaire

Massage Pre-Therapy Questionnaire

Pelvic Floor Dysfunction Questionnaire

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