Confidential Client Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Email
*
example@example.com
Health Fund
e.g. Medibank, Bupa, etc.
Home Address
Street Address
Street Address Line 2
City
State
Postcode
Emergency Contact
*
First Name
Last Name
Phone Number
*
COVID-19
Have you had any cold or flu symptoms within the last 14 days?
*
Yes
No
Have you been in contact with anyone with cold or flu symptoms within the last 14 days?
*
Yes
No
Back
Next
Health Questions
Are you pregnant?
*
Yes
No
How many weeks pregnant? (if applicable)
Do you bruise easily?
*
Yes
No
Do you have hypertension?
*
Yes
No
Do you have heart problems?
*
Yes
No
Do you have cancer?
*
Yes
No
Do you have varicose veins?
*
Yes
No
Do you have?
Hypertension
Heart problems
Cancer
Varicose veins
Please list any medications, accidents, injuries, major illnesses or operations, or other conditions that may be relevant:
What is the primary reason for your appointment?
e.g. frozen shoulder, neck tension, stress or tension, injury or sprain, etc.
On the diagram below please mark any areas of pain or discomfort
Please read:
I understand that the purpose of massage is relief from muscular tension, spasm or pain, as well as stress reduction and improvement of circulation. I give full consent for the therapist to observe, palpate and treat each part of the body as required. I understand the massage practitioner does not diagnose illness or disease.
Signature
*
Submit
Should be Empty: