Health questionnaire

To ensure your treatment goes smoothly, I need you to answer a few questions truthfully. Your answers will remain strictly confidential and for my professional use only.

First name

Surname

E-mail

Phone

Address

Today's date

Month

Day

Year

Your birthday

Month

Day

Year

How did you know me?

My health status

How would you describe your general health?

I pay attention to what I eat, I sleep well, I move.

I'm careful, but with a few minor exceptions. I have trouble controlling my cravings for sugar or coffee. I don't sleep well or not enough.

I'm not doing well at all. I'm eating badly, I'm sleeping badly, I'm not moving. I'd like to get myself back on track.

I am a smoker

Have you ever received a massage or massages in the last six months? If so, which one(s)?

Are you allergic to any oil or anything else? If so, which one(s):

Are there any body parts I should avoid during the massage?

Your female cycle / your pregnancy / your postpartum

Are you pregnant or planning to become pregnant soon?

Yes

No

If you are pregnant, has this pregnancy been defined as a high-risk pregnancy?

Do you know what phase of your cycle you'll be in on the date of our massage? This question allows me to tailor the treatment to your body. It's not mandatory if it's too intimate for you.

Days 1 to 6 – These are the rules

Days 7 to 14 – This is the continuation of the follicular phase which lasts approximately 14 days from the start of menstruation

Days 14 to 20 – This is ovulation, the egg is released and ready to be fertilized. There are approximately 14 days left until your next period.

Days 21 to 28 – This is the luteal phase, it lasts about 14 days, the egg is waiting to be fertilized. This is the pre-menstrual phase

I am on contraception. Reminder: For women on hormonal contraception, the 'natural' menstrual cycle is put on "sleep."

I am menopausal

I have endometriosis

Other

Would you like to receive clinic updates, new treatments, workshops, and wellness retreats by email?

Yes

No

Is there anything else you'd like to add before our treatment?

Health questionnaire

My health status

Your female cycle / your pregnancy / your postpartum

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