My Body Profile

Please ensure that this form is updated if there are any significant changes to your health and/or lifestyle

Name

Birthday

Day

Month

Year

Address

Phone

Occupation*

Hobbies, interests and physical activity*

Medical and surgical history

Please select any of the below conditions that currently apply to you.*

Circulatory disorders (High/Low blood pressure, Thrombosis, Phlebitis, Heart condition etc.)

Varicose veins

Diabetes

Epilepsy

Headaches/Migraines

Cancer/Neuritis/Multiple Sclerosis

Skin disorder or infection

Athlete's foot

Warts/Verrucas

Bruises

Arthritis

Recent fracture, sprain or injury

Operation within the last 6 months

Pregnancy

Allergies

None of the above

If you have selected any of the above conditions, please provide further information here.

If there is anything else you think I should know, please provide details here. This may include particular problem areas you would like me to focus on, or areas of the body that you wish to be avoided.

Alford Ave,

Withington,

Manchester

M20 1AQ

United Kingdom

Garden Massage

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