Client Declaration and Health Information Form

Dear Guest,

efore arriving for your massage, please take a few minutes to read through this declaration. This is not an official “medical form” — it is simply here to help us create a safe, respectful, and calm space for your treatment. The following information will give you clarity on what to expect, and help you decide if this treatment is right for you at this time. Please read everything sincerely and with ease — and if you feel uncertain about anything, don’t hesitate to reach out to me. Thank you for your attention and your trust.

Client Declaration and Health Information Form

Practitioner: VAJDA E., Janka

Date: ………………………………………….……………..……..…..

Name: ……………………………………………………...…………..

Email: …………………………………………….………..…………..

Phone: ……………………………………………………….…….…..

Health Status – Self-Reported

Please answer a few questions to help me ensure the treatment is safe and tailored to your needs:

• Medications currently taken: ………………………………………………………………………………………….……..……………………...
• Current complaints or symptoms: ……………………………..…………………………………………………………………..……………..
• Average daily fluid intake: …………………………………………………………………….……………………………………..………………..
• General lifestyle (sedentary/active, stress level, sleep):………………….……………………………………………..…..………….
• Do you smoke: ☐ yes ☐ no

Declaration:

I understand that the massage treatment is not a substitute for medical or psychological therapy and is not intended for diagnostic purposes.

I confirm that I have no known or undisclosed medical conditions that would contraindicate massage, and I choose to receive this treatment at my own responsibility.

Contraindications include:

• contagious illnesses (e.g. fever, cold, skin infections),
• recent injury or surgery (within 8 weeks),
• severe circulatory disorders,
• epilepsy, untreated high blood pressure,
• severe mental health conditions, psychosis, altered states of consciousness,
• cancer or malignant diseases,
• any condition or illness where treatment may have an impact and has not been recommended by a medical professional.
  
  

I agree to inform the practitioner of any future changes in my health condition.

I am aware that this is a non-erotic massage. Any inappropriate behaviour will result in the immediate termination of the session and may lead to further consequences.

I consent to the safe handling of my personal data in accordance with current data protection laws, exclusively for communication related to treatments.

Signature: ……………………………………………………..

Date: ……………………………………………………..