Name *

First Name

Last Name

Do you have any allergies? If yes, please give details. Please also include allergies to cleaning products, latex, etc for massage purposes. *

YES

NO

Do you suffer from Diabetes? If yes, what type is it and how is it managed? *

YES

NO

Do you suffer from a cardiac condition? If yes, please outline the condition and management *

YES

NO

Do you have high blood pressure? If yes, is it managed and how? *

YES

NO

Do you suffer from a respiratory condition? If yes, please outline the condition and management. For example, asthma *

YES

NO

Do you suffer from any digestive problems? If yes, please outline the condition and management. *

YES

NO

Do you suffer from an auto immune disease? If yes, please outline the condition and management. *

YES

NO

Do you have arthritis? If yes, what type and in which joints? *

YES

NO

Do you suffer from epilepsy or seizures? If yes, how are they managed and when was the last episode? *

YES

NO

Are you suffering from any contagious condition eg athletes foot etc? If yes, please outline here. *

YES

NO

Are you currently undergoing treatment for cancer? If yes, please outline current stage. *

YES

NO

Have you recently been hospitalised? If yes, please give details below. *

YES

NO

If you have any other medical condition please outline here: *

YES

NO

Are you pregnant? *

YES

NO

Are you aged 70 or over?

UNDER 70

70 OR OVER

Are your symptoms affecting any of the following?

Your Daily Activities

Your Ability to Work

Your Sleep

Your Ability to Exercise

Your Mental Health

Sports Massage and Fitness Coaching Consent: Sports Massage: I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension and myofascial pain conditions suitable for treatment using soft tissue therapies. If I experience any pain during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a doctor, chiropractor or qualified medical specialist for any mental or physical ailment of which I am aware. I understand the massage therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I declare that the information I have provided is true and correct and I make this declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false, then I am aware I can be prosecuted for making a false declaration. If you test positive for Covid-19 then you are obliged to inform me due to close contract treatment. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. I acknowledge that should I be late for my appointment the therapist has the right to alter the length of my massage to suit the needs of the clinic schedule. Fitness Coaching: I recognise that the fitness coach is not able to provide me with medical advice regarding my medical fitness and that the information is used as a guideline to the limitations of my ability to exercise safely. I have answered the questions to the best of my ability and understand the advice. I also state that I wish to participate in activities which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves risk of injury and even possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me. I have read and understood the terms and conditions above and agree to abide by them

I have read and understood the Privacy Policy and agree to the collection and use of my personal data in accordance with the terms of the Privacy Policy. *

I agree

Please tick this box if you wish to receive marketing material from Carrieluxembourg.com

I wish to receive marketing material

Please click on the T&C's link below to take you straight to my Terms & Conditions including my cancellation policy . *

I have read and agree to your Terms and Conditions