Medical History Form
Full Name (You may be asked to present ID at your first appointment)
*
First Name
Last Name
Date of Birth DD/MM/YY
Emergency contact number
Format: (000) 000-0000.
Check the conditions/precautions that apply to you
Clots/circulatory/cardiovascular disorder NB!! Massage not suggested with clots/embolism/DVT risk
Cancer
persistent muscle pain
Diabetes
persistent nerve pain
Epilepsy
neurological challenges/diagnoses
Mental health diagnoses/challenges (depression, anxiety etc)
Pregnancy
fibromyalgia
Skin condition (especially if contagious)
osteoporosis
loss of/reduced organ function
chronic sinus/asthma
arthritis
contagious condition
current cold/flu symptoms including fever
hypermobile
List repetetive actions/activities that may affect your posture, tension, or pain. (eg: desk job, runner, active/standing job)
List other notable diagnosed conditions/precautions/mental health challenges/ physical trauma, surgeries if relevant
If seeking to manage mental health, explain your challenges and goals in as little or as much detail as you are comfortable with (EG: insomnia, anxiety, work stress, depression, traumatic event, family issues, grief, addiction etc)
Are you consistently taking any prescription medication?
Yes
No
Please list them, or what they are prescribed for.
Do you have fatal anaphylactic allergies of any kind, or allergies relevant to a massage environment/aromatherapy oils?
Yes
No
Please list them
Relevant religious/cultural considerations
Areas to avoid (broken skin, pain, sensitivity, trauma, general discomfort)
I am aware that sexual services are not offered by the therapist. TMT is a health profession, regulated by the Allied Health Professions Council of South Africa.
*
I am able to respect and maintain professional boundaries within a therapeutic health setting.
I hereby consent to therapeutic massage treatment and promise to disclose relevant medical info to reduce harm or risk. I will not hold the therapist liable for consequences of massage on unknown/undisclosed health issues that are contraindicated.
*
Yes
Do you have or have you had hip or lower back pain?
Yes
No
On and off but not currently
List UP TO 3 clear goals for your first treatment from highest to lowest priority EG - 1. shoulder pain, left side only, pain extends into left arm 2. manage depression 3. sports support. Be Specific! Treatments can be adjusted to manage or treat many conditions from diabetes to high blood pressure or depression.
*
If needed, add a list of health and wellness concerns to address in future appointments, that may not be a priority for your initial visit.
Where did you hear about me?
google search
referred by heath professional/therapist
referred by a friend/family
instagram
Other
(Optional) Feel free to upload X-rays, reports and assessments provided by other health professionals if relevant and available.
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