Par Q — Muscle Flow Massage

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) AND CONSENT FORM

ParQ / Consent form

First Name

Last Name

Date of Birth

Address

Postcode

Contact number

Email address

1. Have you ever been diagnosed with a heart condition or circulatory problem (e.g., high/low blood pressure, angina)?

(If yes, please provide details):

2. Do you experience chest pain during or after physical activity?

3. Do you have varicose veins, blood clot history (e.g., DVT), or circulatory issues?

(If yes, please provide details):

4. Do you have any injuries, pain, or discomfort in the following areas? (Please tick if applicable):

(If ticked, please provide details):

5. Have you had any surgeries, fractures, or recent injuries?

(If yes, please provide details):

6. Do you experience muscle stiffness, pain, or spasms?

7. Do you have any joint instability (e.g., dislocations, ligament damage)?

8. Do you have any skin conditions (e.g., eczema, psoriasis, infections)?

9. Are you allergic to any products (e.g., oils, creams, latex)?

(If yes, please provide details):

10. Have you been diagnosed with any neurological conditions (e.g., sciatica, epilepsy, MS)?

11. Do you experience numbness, tingling, or loss of sensation?

12. Do you have any chronic illnesses or conditions (e.g., diabetes, arthritis, asthma)?

(If yes, please provide details):

13. Do you have cancer or are you undergoing cancer treatment?

(If yes, please provide details):

14. Do you have any other medical conditions not listed above?

(If yes, please provide details):

15. Do you smoke or use tobacco products?

16. How often do you exercise?

17. Do you experience high stress levels or difficulty relaxing?

18. Are you pregnant, or have you given birth in the last 6 months?

Emergency contact - Full Name and contact number

Consent for Treatment - By ticking the checkbox below and submitting this form, I confirm the following: I have answered all questions truthfully to the best of my knowledge. I will notify my therapist of any changes in my health before future treatments. I understand that massage therapy involves physical manipulation of the body and may cause temporary discomfort, soreness, or bruising. I understand that massage therapy is not a substitute for medical treatment or diagnosis and does not replace medical advice. I agree to communicate with my therapist immediately if I experience any discomfort during the session. I consent to receiving massage therapy under the care of my therapist. - Data Protection (GDPR Compliance) Your personal and health information will be stored securely and will only be used for the purposes of providing safe and effective treatment. It will not be shared with third parties without your explicit consent, except where required by law.

I declare that I have read and understood this form and give my informed consent to participate in massage therapy sessions. By ticking this box and clicking “Submit,” I confirm my consent.