top of page
Home
Treatments
Book here
Contact
Shop
More
Use tab to navigate through the menu items.
Anamnese form
Date intake
Name
Surname
Email address
Date of birth
Phone number
Address
Do you have a medical condition, illness, injury right now?
*
No
Yes
If your answer is 'yes'. What kind of medical condition, illness, injury do you have right now?
Have you had serious illness in the past?
*
No
Yes
If your answer is 'yes'. What kind of serious illness? How long ago? Are you fully cured right now?
Do you have any allergies?
*
No
Yes
If your answer is 'yes'. What kind of allergies do you have?
How long ago did you have surgery? Were there any complications? If so, please describe below
What is the name of the medical clinic you got operated on?
Do you take any medication?
*
No
Yes
If your answer is 'yes'. What kind of medication? For what reason?
Initialen
By signing this form, I declare that I have read, understood and truthfully filled in all the questions. I will immediately pass on any interim changes to the massage therapist. I will let the massage therapist know immediately if I experience any pain or discomfort during the treatment. I undergo the treatment of my own free will and take responsibility for it.
Send
Thank you!
bottom of page
