Health questionnaire: Massages and treatments

Personal details

Full name (required)

Date of birth

Phone

Email

Occupation / usual activity

Today’s date

Emergency contact

Phone

Reason for your visit

Other

Other — what?

What would you like to improve or achieve with the session?

Areas with discomfort, pain or sensitivity — say since when and, if relevant, the diagnosis

Session preferences

Preferences, discomforts or limits you’d like to mention

Informed consent

I confirm that the information I have given is true and complete to the best of my knowledge, and I will report any relevant change before each session.

I understand that Estructura’t’s services are for wellbeing, personal care and body support. They do not replace a diagnosis or any medical, physiotherapy, psychological or other healthcare treatment.

I understand that I can ask questions, change the pressure, decline a technique, exclude any area or stop the session at any time.

I authorise the agreed service, taking into account the information in this questionnaire and any adjustments the practitioner considers necessary within their scope of practice.

I accept that, if there is a contraindication or a safety concern, the session may be adapted, postponed or require prior assessment by a healthcare professional.

Privacy and communications

Data controller: Estructura’t (hello@estructurat.com · +376 323 327). We process the information in this questionnaire, including health data, with your explicit consent and only to tailor our services and carry them out safely. If you send it to us by WhatsApp, we save it to the studio’s records and delete it from the chat once received. You can exercise your rights of access, rectification, erasure, objection, restriction and portability, and withdraw your consent at any time, through the same contact channel, and lodge a complaint with the Andorran Data Protection Agency (APDA).

I give my explicit consent to the processing of my health data for this purpose. (required)

If I send it by WhatsApp, I accept this channel for delivering it to Estructura’t.

I agree that Estructura’t may contact me to manage appointments and follow-up.

I agree to receive marketing information and news. Optional; I can withdraw this at any time.

Signatures

Client name

Date (required)

Client signature (required)

Sign with your finger or mouse inside the box

Your phone’s share menu will open: choose WhatsApp and the Estructura’t chat.

Massages and treatments

Personal details

Reason for your visit

Current health

Medical history and precautions

Skin, tissues and sensitivities

Pain and mobility

Session preferences

Habits and wellbeing

Informed consent

Privacy and communications

Signatures