Fiche santé | Cesario massothérapie

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Health record

Strictly confidential information

First name*

Surname*

E-mail

Date

Phone*

Sex*

Women

Man

Age*

Occupation*

Sports, physical activities*

First time getting a massage?*

Yes

Would you like an insurance receipt?*

Yes

Questions related to your health

Cancer, hemophilia*

Yes

Allergies (Food Products)*

Yes

Contagious diseases*

Yes

Fatigue, stress, anxiety, depression, insomnia*

Yes

Cardiac conditions (pacemaker)*

Yes

Circulatory conditions (hyper/hypotension, phlebitis, thrombosis, stroke)*

Yes

Digestive conditions (bloating, constipation)*

Yes

Skin problems (eczema, psoriasis, warts, athlete's foot)*

Yes

Cervical osteoarthritis, osteoporosis, arthritis*

Yes

Diabetes, hypoglycemia*

Yes

Neurological disorders (migraine, epilepsy, paralysis)*

Yes

Respiratory problems (asthma, bronchitis, flu)*

Yes

Hormonal disorder (hyper/hypothyroidism)*

Yes

Do you take any medications ?*

Yes

If so, which ones?

Have you recently undergone surgery, fractured, injured or had an accident?*

Yes

Are you pregnant?*

Yes

If so, how many weeks?

Medical history

This information is confidential and cannot be disclosed without your consent.

I certify that the above information is accurate and complete.*

Yes

514 576-8288

cesariomassotherapie@hotmail.com

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