Health questionnaire

To ensure your treatment goes smoothly, I need you to answer a few questions honestly. Your answers will remain strictly confidential and for my professional use only.

First name

Surname

E-mail

Phone

Address

Today's date

Month

Day

Year

Your birthday

Month

Day

Year

How did you find out about me?

My state of health

How would you describe your general state of health?

I pay attention to what I eat, I sleep well, I exercise.

I'm careful, but I do slip up a few times. I have trouble controlling my cravings for sugar or coffee. I don't sleep well, or not enough.

Things aren't going well at all; I'm eating poorly, sleeping poorly, and I'm not exercising. I'd really like to get my life back on track.

I am a smoker

Have you received any massages in the last six months? If so, which ones?

Are you allergic to any oil or anything else? If so, which one(s)?

Are there any body parts I should avoid during the massage?

Your menstrual cycle / your pregnancy / your postpartum period

Are you pregnant or planning to become pregnant soon?

Yes

No

If you are pregnant, has this pregnancy been classified as a high-risk pregnancy?

Do you know what phase of your cycle you'll be in on the date of our massage? This question helps me tailor the treatment to your body. It's not required if this is too personal for you.

Days 1 to 6 – These are the rules

Days 7 to 14 – This is the continuation of the follicular phase, which lasts approximately 14 days from the start of menstruation.

Days 14 to 20 – This is ovulation; the egg is released and ready to be fertilized. There are approximately 14 days left before the next period.

Days 21 to 28 – This is the luteal phase, lasting approximately 14 days, during which the egg is awaiting fertilization. This is the premenstrual phase.

I am on contraception. Reminder: For women on hormonal contraception, the 'natural' menstrual cycle is put on hold.

I am menopausal

I have endometriosis

Other

Would you like to receive updates about the clinic, new treatments, workshops, and wellness retreats by email?

Yes

No

Would you like to add anything before our treatment?

MENU

+(972) 054-49 88 090
+(33) 06 93 48 32 25

Health questionnaire

My state of health

Your menstrual cycle / your pregnancy / your postpartum period

© 2025 CLAIRE MARGOLIS

MADE BY AMOUR SOCIAL

MENU

+(972) 054-49 88 090 +(33) 06 93 48 32 25

Health questionnaire

My state of health

Your menstrual cycle / your pregnancy / your postpartum period

© 2025 CLAIRE MARGOLIS

MADE BY AMOUR SOCIAL

+(972) 054-49 88 090
+(33) 06 93 48 32 25