medical history form Lass dieses Feld leer Your e-mail address First and Last Name Street Postcode / town date of birth telephone (optional) How did you hear about us Choose Google search social media flyer personal recommendation other Please tick if it applies to you (optional) Your first massage Currently receiving medical treatment Has had an operation in the past few months Currently taking medication Exercise regularly I have prostheses I can lie on my stomach and back without any problems Do you have allergies? If yes, which? (optional) Do you suffer from any of the conditions listed? (optional) Open wounds Disc prolapse scoliosis migraine high blood pressure low blood pressure fever epilepsie osteoporosis rheumatic diseases How sensitive are you to pressure? (optional) not at all a little normal very sensitive Health insurance (optional) Additional insurance (optional) Do you have any other information that may be of interest for the massage? (E.g. fragrances that you don't like) (optional) Send