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Personal and Health Data Module

If this is the first Massage with Wellness Delivered, please fill carefully the following form. This will certainly help us offering you the best and the healthiest experience, custom-tailored for you. 

About you

Date of Birth

Gender

How to contact you

About your coming soon Massage

Is it your First Massage?
Purpose of the massage

If "Other" please specify in belove "Other Notes" field

Do you pratice sport?
How do you hear about us?

Any special request for this massage?

Please specify here if you want special part or area of the body to be treated or a technique / intensity you like

If "Other" please specify in belove "Other Notes" field

About your Health

Any ACTUAL problem with muscloskeletal system?

E.g.:
back, joint,
muscle pain

Any CHRONIC compliants on muscoloskeletal system?

If "Yes" please specify in belove "Other Notes" field

If "Yes" please specify in belove "Other Notes" field

Have you ever had a slippled disc?
Do you have any artificial joint

If "Yes" please specify in belove "Other Notes" field

If "Yes" please specify in belove "Other Notes" field

Do you have osteoporosis?
Do you have diseases of the cardiopulmunatory system?

E.g.:
heart rythm, blood pressure, ashtma

If "Yes" please specify in belove "Other Notes" field

If "Yes" please specify in belove "Other Notes" field

Any varicose vein oe have you ever suffered thrombosis?
Are you under medical treatment?

If "Yes" please specify in belove "Other Notes" field

If "Yes" please specify in belove "Other Notes" field

Do you take any medication?

If "Yes" please specify in belove "Other Notes" field

Do you have cancer?
Have you had any surgery recently?

If "Yes" please specify in belove "Other Notes" field

Do you have metabolic diseases

E.g.:
thyroid gland, diabetes

If "Yes" please specify in belove "Other Notes" field

If "Yes" please specify in belove "Other Notes" field

Do you have any allergy?

If "Yes" please specify in belove "Other Notes" field

Do you have any foot fungus?

If "Yes" please specify in belove "Other Notes" field

Do you currently have a cold, fewer, infiammation?

If "Yes" please specify in belove "Other Notes" field

Are you pregnant?

If "Yes" please specify in belove "Other Notes" field

Do you have stress, headaches?

If "Yes" please specify in belove "Other Notes" field

Other Notes - Specifications (if you answered yes to any of the above health's question, please specify here)

We consider your Privacy as our priority

All data in this form submitted by you will be managed accordingly to the swiss privacy law and they won't be distributed outside the organization or used out of the scope of your massages. You will ever have all rights to modify or delete them, anytime. 

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