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Health Declaration

Please fill out the following form to help us understand your health condition and provide the safest, most effective massage experience tailored to your needs

Health Declaration

Please fill out this form so we can tailor your massage safely and effectively to your needs

Full Name *

Email *

Phone Number *

Date Of Birth *

(DD/MM/YYYY)

Country of Residence *

Medical History

Please choose the appropriate answer if you are currently suffering from any of the following

High or low blood pressure *

Yes

No

Thrombosis / Varicose Veins *

Yes

No

Heart condition *

Yes

No

Hormonal Imbalance *

Yes

No

Thyroid Condition *

Yes

No

Epilepsy *

Yes

No

Herpes *

Yes

No

Skeletal / Joint Problems *

Yes

No

Diabetes *

Yes

No

Claustrophobia *

Yes

No

Skin Diseases / Skin Allergies *

Yes

No

Allergies to Seaweed or Iodine *

Yes

No

Asthma *

Yes

No

Cancer *

Yes

No

Do you have any other condition not listed that could affect your treatment options, such as slow healing, bruising, sensitivity to cosmetic ingredients etc?

Explain here

Have you had any surgery in last three year? If yes, please state

Are you currently taking medication? If yes, please state

Any additional comments you may want to add?

Only for Ladies

Are you Pregnant? If yes, how far along

Are you currently menstruating?

I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. DS Holistic Therapist will not be liable for contra-indications to treatments due to medical information withheld or for any personal valuables, belongings that are brought into the studio.

Signature *

Type your full name

I declare that the info I’ve provided is accurate and complete

Submit

Name

2 July 2026

© 2026 DS Holistic Therapist