Client Registration Form

1
Name
2
Date of Birth
Date
Day
Month
Year
3
Gender
Female
Male
Other
4
E-mail
5
Phone Number
Please enter a valid phone number.
6
Please describe your pain and location(s) of your pain
eg. Stabbing in my left shoulder
7
From 1 to 10, How bad is your pain
1
2
3
4
5
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8
9
10
Not much
Very bad
8
Can you describe the feeling of your pain?
Burning
Stabbing
Penetrating
Numb
Nagging
Gnawing
Aching
Throbbing
Tender
Shooting
Sharp
Intermittent
Unbearable
Constant
Other
9
Type a question
Rarely
Sometimes
Often
Continuous
10
In which period of the day you feel the pain mostly?
Morning
Afternoon
Evening
Night
Other
11
How is your pain getting by the time?
Getting Better
Getting Worse
12
Is there something that you do to get better when you feel pain?
eg. massaging my forehead
13
Is there any movements, actions or activities that triggers your pain?
eg. Raising my hand
14
Are you taking any medicine or medical assistance for your pain? If you do, please type the name and type how often do you take
eg. Nurofen = 1 per day
15
Please select the option; how the pain affects your
1A little
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10So much
Sleep
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Daily routine
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Your work
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General mood
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Relationships
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Life quality
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Sleep
Daily routine
Your work
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Life quality
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Terms and Conditions
17
Informed ConsentI am aware that draping will be used during the massage session. I understand that it is not within the scope of the massage session for the therapist to engage in breast massage of female clients. I understand my therapist is NOT engaging any sexual conduct, sexual activities, or sexualizing behavior involving a client or pertaining to the practice of massage therapy. If I am unable to keep an appointment, I understand that an 24 hour notice is required. I hereby consent for my therapist to treat me with massage therapy techniques recommended. I acknowledge the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
18
Please verify that you are human
19
Please Sign and Submit.
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