THAI MOBILE MASSAGE THERAPY   นวดแผนไทย กับ ไทยโมบายมาสซาสเทอร์ราปี

I am:
Male Female
First name:

Surname:

Occupation:

Date of birth:

Nationality:

Address:

City:

Post Code:

Country:

Email:

Telephone:

Mobile

1.With the 2 years. Have you had or in suffering from major opeation?
Yes No
If Yes, please state

2. With the 2 years. Have you had or in suffering from injuries, bone fractures of joint dislocation?
Yes No
If Yes, please state

3. With the 2 years. Have you had or in suffering from skin diseases or allergies? (e.g. Psoriasis, Eczema)
Yes No
If Yes, please state

4. Have you had or suffering from contagious ilness?
Yes No
If Yes, please state

5. Have you had or suffering from malignant condition?
Yes No
If Yes, please state

6. Are you currently taking any medicaition?
Yes No
If Yes, please state

7. Are you generally in good health?
Yes No
If No, please state

8. Do you smoke or drink?
Yes No
Please state

9. Have you ever had a massage before?
Yes No
If Yes, please state the type of massage

10. Are you currently suffering from any fever?
Yes No
11. Are you currently suffering from Heavy Discharge?
Yes No
12. Are you currently suffering from abdominal pain?
Yes No
13. Are you currently suffering from Asthma?
Yes No
14. Are you currently suffering from Epilepsy?
Yes No
15. Are you currently suffering from Diabetes?
Yes No
16. Are you currently suffering from Varicose Veins?
Yes No
17. Are you currently suffering from High blood pressure?
Yes No
18. Are you currently suffering from Diarrhoea?
Yes No
19. Are you currently suffering from Headche/Migraines?
Yes No
20. Are you currently suffering from Sciatica?
Yes No
21. Are you currently suffering from muscles cramp?
Yes No
22. Are you currently suffering from neck and sholder pain?
Yes No
22. Are you currently suffering from backache?
Yes No
23. Are you currently suffering from tension?
Yes No
24. I have answered and understood all of the above questions to the best of my ability and the answers given are correct.