online questionnaire

Thank you for filling out the form below. The fields marked with (*) are required fields.
*	FIRST Name	* required
*	LAST Name	* required
*	DATE of Birth	* required
*	EMAIL	* required
	DO YOU HAVE ANY OF THESE?	Cancer, Heart conditions, Epilepsy, Arthritis, Thyroid (hyper or hypo) condition, Hormonal Imbalances, Open wounds, Varicose Veins, Bruising, High/Low Blood pressure (medicated or not) Claustrophobia, Asthma, Back Spinal/Muscular conditions of any kind, Fractures, Headache/Migraine, Diabetes, Pacemakers, Other Medical / Physical, Emotional or Mental Health Issues that may influence treatment
	Has your doctor / health physician ever advised you to NOT have massage or spa treatments	Yes No
*	Are you taking ANY medication?	Yes No
*	Serious Illness? Currently or in the past	Yes No
*	Allergies? do you have any reaction or aversion to any oils, fragrances or plant materials?	Yes No
	is there a particular area you want me to avoid?	Yes No
*	Understanding that the massage is conducted professionally by a qualified therapist you are welcome to enjoy the treatment fully disrobed &/or draped/undraped. Please advise the therapist if, at anytime, you wish to change your decision or if they can increase your comfort in any way. ..I understand that massage therapy and bodywork services provided by The Peace Company Pty Ltd & Michael Joseph Rees is for the purposes of stress reduction, relief from muscular tension and spasm, general relaxation, and improvement of circulation and energy flow. ..I understand that The Peace Company Pty Ltd & Michael Joseph Rees and its associated massage therapists do not diagnose illness, disease, or any other physical or mental disorder. The therapists do not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations. ..I understand that this is a strictly NON-SEXUAL service & that it is illegal to request anything of a sexual nature. I also understand that it is illegal to make false claims or allegations against a health professional or any person under Australian Law. ..I understand that services offered by The Peace Company Pty Ltd & Michael Joseph Rees are not a substitute for medical care and that any information provided by the therapist is for educational purposes only, and is not diagnostically prescriptive in nature. ..I have stated all of my known medical conditions on this Health Form. ..I realize it is solely my responsibility to keep the massage therapist updated on any changes in my physical health and I understand that neither The Peace Comany Pty Ltd & Michael Joseph Rees nor the therapist shall not be liable should I fail to do so. ..If at any time during the massage session I experience pain or discomfort of any kind or require more (or less) draping, or feel that my privacy has been compromised I agree to inform the massage therapist immediately and/or terminate the session at my discretion. I agree to say the word ‘ok’ or similar word that we both agree on to signify to Michael when has reached the maximum pressure or style I am willing to take on any given area. I understand that there may been some minor discomfort when having a deeper style of massage and will notify Michael immediately if this discomfort goes beyond what I am willing to accept. I understand that Michael considers my safety & privacy as paramount & agree to comply to requests by Michael to ensure these priorities are maintained. ..By signing this release I hereby waive and release The Peace Company Pty Ltd & Michael Joseph Rees., the massage therapist, from of any and all liability, past, present, and future, relating to massage therapy and bodywork. In addition, I agree to indemnify and hold them harmless from and against any and all claims, demands, fines, suits, actions, orders, or damages of any kind which may arise or result out of or from my utilization of The Peace Company Pty Ltd & Michael Joseph Rees' on-site massage program.	Yes...I FULLY Understand & Agree with the aforementioned No.