Client health form

Consultation form

Traditional full body Ayurvedic Yoga Massage treatments include massaging the back, neck, shoulders, arms legs, gluteal muscles, abdomen, chest (not breast area for women, unless this is requested), head and  face. In remedial treatments (where we work on a part of the body that is tense or injured) we might spend  more time on some parts of the body, and miss out other parts due to time constraints.

If there are any parts of your body that are sensitive to touch, or that you would prefer not to have massaged, please inform your therapist. Your boundaries will be respected before, during and after your treatment, and we strongly encourage you to tell your therapist if any part of the treatment or the way the therapist communicates is uncomfortable or unpleasant for you.

The intensity of the treatment is entirely up to you, and how you feel on the day. If you are ready to receive  a fairly challenging treatment, where we work on long-term held tension with deep pressure, that is entirely  possible. Or we can work with a more gentle pressure if you need a nourishing treatment, or your nervous system is sensitive on the day.

Clients need to be respectful at all times. If you are not prepared to respect your therapist's professional boundaries please do not make a booking with us. Any harassment of our therapists in the form of requests of a sexual nature will be reported to the police.

Clients are required to wear comfortable underwear during their treatments, and accept that any parts of the body that are not being massaged will be covered with sheets.

By booking this treatment you consent to receive an Ayurvedic Yoga Massage treatment. You agree to undergo this treatment at your own risk. You have been informed of the nature and purpose of the treatment. You understand that any information that you share with us as part of your consultation and treatment will be kept confidential.

By submitting this form you are agreeing to the above terms and conditions, and confidentiality agreement.

Please complete as fully as you can. This information will be used to inform your treatment. It will be kept confidential between you and your therapist, and stored securely. Your therapist might share anonymous information about your treatment with their teacher during their supervision/mentorship meetings or future trainings in order to receive relevant guidance and feedback to improve as therapists, but they will not share anything that could identify which client they are referring to.

We collect and store your data in accordance with GDPR guidelines. Please confirm that you accept for your information to be shared with your therapist, stored and used as outlined above.

I accept that my information will be used as outlined above

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

How did you hear about Satmya Massage?

Do you wish to be added to the mailing list?

Yes

Date of birth

YYYY

Emergency contact name

Emergency contact phone number

Profession/movement during a typical day

(If you are in employment, do you usually work at a desk, standing, is it manual work, do you lift heavy items, do you move regularly or get regular breaks for movement during your work? If you are not in employment what is your lifestyle like in terms of movement?)

Exercise and other movement

(Do you exercise regularly, including regular walking or cycling? Please briefly outline your usual exercise activities, frequency, intensity):

Health conditions, medications and ongoing treatment

(Do you have any health conditions, such as heart/circulatory system conditions, nerve conditions, respiratory conditions, gland conditions, diabetes, infectious diseases of the respiratory or other systems, skin infections? Are you undertaking any medical treatment, including prescription medication, hormonal treatment? How are your energy levels? Is there anything that we need to avoid because of your health condition(s), or anything that you find particularly helpful?):

Mental health

(How is your mental health at the moment? Do you suffer from any mental health conditions or conditions that might influence your stress hormones? Are you on any medication for your mental health, including psychiatric drugs?):

Pains and aches

(Do you have any pains or aches? Where are they located? How long/when did the pain start? Does it feel like muscle pain or is it related to nerve compression/pathologies? Is it a dull or sharp sensation, is it at a very specific point or a large area, or does it move/occur at different parts of the body at different times? What are your pain levels currently, how do your pain levels usually vary, what tends to help and what tends to worsen the pain? Have you had treatments before, and if so how did they influence your pain levels? What have you found helpful/unhelpful in the past?)

Priorities for treatment

(What would you like to get out of this treatment? E.g. we can help with overall relaxation, which can help with immune system function, sleep, energy levels and digestion; we can help with any pains and recovery from injuries; we can help with stiffness and restrictions to movement; with posture and breathing capacity. The treatment can have one or multiple objectives. It can focus on one or more areas that need attention, or we can aim to offer a full body treatment, and spread the time evenly between different parts of the body.)

Any allergies/skin sensitivity:

Areas to exclude from treatment

(Are there any areas of your body that you would prefer not to include in the treatment? Ayurvedic Yoga Massage treatments might cover massage, mobilisations and stretches of the back, shoulders, arms, neck, legs, gluteal muscles, feet, abdomen, chest for men (your therapist might also be trained in breast massage for women, but we do not usually offer this in the first treatment/without a prior discussion with the client), head and face, including the ears and light pressure on the eyes. Please let us know if you tend to get ticklish in any parts of your body, or find touch uncomfortable/painful.)

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