Body In Mind Therapies Consultation Form

Client Consultation Form

All information is held strictest confidence. At no given point is information disclosed or shared without your written consent.

All essential fields are marked with a red asterisk.

You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Please put N/A for any question marked with an asterisk which doesn't relate to you.
Full Name*

First NameLast Name
Date*

DayMonthYear
Address*

Street Address

Street Address Line 2

Town/CityCounty

PostcodeCountry
Birth Date

DayMonthYear
Phone Number

Area codePhone Number
E-mail
Emergency Contact*
Emergency Contact Phone Number*

Phone Number
Your Occupation
Name of GP Surgery

NameTown/City
Do You Take Any Medication? Please list if yes*
Allergies*
History of Pathology (i.e. any injuries, surgery, current aches, pains or tension)
1. List Areas of any Discomfort or Pain*
2. Describe Onset of Discomfort or Pain*
(i.e. how and when it started, what happened)
3. Level of Pain Today*
ConstantOff/OnAt RestWith ActivityN/AOther
MorningAfternoonEveningDuring SleepN/AOther
6. Have you ever injured this area before?*
7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
8. If yes, list all related treatments received for the injury.
9. Have you ever received therapeutic massage for a specific problem or injury?
What type of massage?
10. Is there anything that you do that creates, increases or decreases pain? *
11. Are there any physical duties required of your occupation?*
12. What activities/hobbies do you enjoy?*
13. How are your energy levels currently on a scale from 1 (low) to 10 (high)?*
14. How are your sleep patterns and how many hours do you sleep per night?*
15. Please list any exercise and stress reduction / relaxation activities (including frequency).*
AlcoholCaffeineNicotineRecreational drugsOther
17. If you ticked any of the boxes above please state quantity and frequency of use*
Type N/A if not
BackSideStomachOther
19. Are you currently seeing any other healthcare professional? *
20. Please describe your typical daily diet and fluid (water, juice, herbal tea) intake*
Please check any symptoms that apply to you and indicate right or left when applicable:
TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Pain in shouldersFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther
Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther
Please describe
Low back painLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingPinched nerve in low backPain up/down low backPain across low backDiagnosed disc herniationOther
Please check any of the following conditions that apply to you:
High blood pressureLow blood pressureVaricose veinsOedemaBlood disorderPrevious Heart attackDeep Vein ThrombosisArteriosclerosisHaemophiliaPoor circulationOther
EczemaPsoriasisInfectionParasitesBruisesBlistersAcneOther
BreaksFracturesOsteoporosisRheumatismArthritisPostureOther
SprainStrainSlipped discMuscle tearOther
EpilepsyHeadachesMigrainesPrevious stroke / T.I.A.Other
DiabetesHypothyroidHyperthyroidOther
AsthmaHayfeverInfectionOther
I.B.S.ConstipationOther
Currently menstruatingP.M.SOther
Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your mobile phone for optimal relaxation.

       • Please allow a littel extra time at the start and the end of your treatment to allow for you therapist to set up and take down if mobile.

       • 24 hour cancellation notice is required to avoid being charged for your treatment.

       • You will have a prior consultation with your therapist to discuss your treatment.

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.

Client Agreement:

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy

I also undersand that at any time I feel pain or discomfort during the treatment, I will immediately inform my therapeutic massage therapist so they adjust their technique accordingly.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I absolve Body In Mind Therapies or my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature*

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