Client Health History Intake Form

CLIENT INTAKE FORM

BROULEE MASSAGE
PLEASE READ:

Broulee Massage is certified in Relaxation and Remedial Massage Therapy, Traditional and Modern Cupping Therapy and Pregnancy/Prenatal Massage and Oncology Massage. Your careful responses to the questions asked in this client health history online form will help your Therapist to ensure that any risks are minimised and the appropriate care is provided to you. Please remember your assigned therapist can only work within their scope of practice as per their certifications and level of training - after we review your responses from your client health form; this could determine that your therapist is not qualified to perform a treatment on you and will provide a referral to the appropriate practitioner to contribute to the safest outcome for your health and wellbeing. PLEASE NOTE: Broulee Massage is not trained in Aromatherapy Massage, Reflexology Massage, Shiatsu Massage, Myotherapy, Thai Massage, Chinese Massage, Cranial Sacral Therapy or Lymphatic Drainage Massage.
1. Please select below what upcoming treatment you are booked in for (NOTE: For body packages that include a Sauna session, please exit this form and fill out the Sauna intake form via our website instead).*

REMEDIAL MASSAGE *private health rebates accepted for this service, see Qu. 1a.RELAXATION MASSAGE.PREGNANCY MASSAGE.ONCOLOGY MASSAGE.CUPPING COMBINED THERAPY.
1a. If you would like to claim a rebate from your private health insurance for your Remedial Massage, please provide the name of your health fund so we can prepare your receipt after your treatment. Full payment is due after your massage, and you'll receive a receipt to submit to your health fund for partial reimbursement/rebate.
The name of my private health fund is: .
2. Please reschedule if you have been unwell in the past 7 days; this policy forms part of our general onsite infection control procedure.*

YES ( I have been unwell & will call Broulee Massage to reschedule on: 0415 567 439).NO ( I am well and will be attending my massage appointment).Other
2a. Have you ever had a treatment from AJ at Broulee Massage before?*

YES.NO.
3. We are a business and late cancellations (within 24 hours) need to be accounted for. If you are a member or have an eGift card, we will still require your Credit or Debit card details to secure your appointment(s) online, no amount is withdrawn from your card when booking in online. We have implemented a 50% cancellation fee policy to ensure that we are no longer at a loss when people fail to show up or give reasonable notice prior to their appointment time. This 50% fee will only be charged from the card details you provided when booking in, if you cancel within 24 hours.*

Yes, I understand.
4. Name (first + last):*

First NameLast Name
5. Birth Date (you must be 18+ to receive a Massage with Broulee Massage - this forms part of our Massage Associations code of practice).*

DayMonthYear
6. Phone Number & Occupation*
7. RESIDENTIAL POSTCODE:
THIS FIELD IS OPTIONAL.
8. eGift Cards: Will you be using a Gift Voucher at the time of your treatment? If so, please bring with it with you (printed copy OR phone display) you can also enter your gift voucher code here below (optional).
THIS FIELD IS OPTIONAL. .
8a. Are you a member of 'The Quest' via Metamorph Mobile Health & Fitness?*

Yes (Thanks! We'll cross check your name from the list).Not applicable.
9. Email address:
THIS FIELD IS OPTIONAL.
10. Medical Emergency Contact Name, Relation to you & their Contact Number.*
MEDICAL HISTORY
11. Are you Pregnant:*

Yes (fill in text box below 11a.)No (skip to Question 12).
11a. If yes, please list: (a) How many weeks gestation are you? (b) The date of your last prenatal appointment? + BP reading? (c) Has your doctor/midwife indicated that you are a high or low risk pregnancy? (d) Are you experiencing any pregnancy conditions? (e) Have you had a professional pregnancy massage before from a trained pregnancy massage specialist?
12. Do you have Cancer:*

Yes (fill in text box below 12a.)No (skip to Question 13).
12a. If yes, please provide as much information as possible so we can best determine a safe treatment plan for you (please note a further in depth oncology massage consultation will be required on the day of your appointment). Please refer to our prompt questions below in our sublabel.
1. Date of diagnosis? 2. Name of GP/oncologist? 3. What type of cancer(s) and where? 4. Have you received any treatment/surgery or radiation for your cancer & when? 5. Do you have a low white blood cell count? 6. Current fatigue levels? 7. Do you have any tingling in your fingers or toes (peripheral neuropathy)? 8. Have you had lymph nodes removed or a sentinel node biopsy (if so, how many & where)? 9. Do you have any oedema or lymphedema? 10. Do you have any bone density loss, if yes, where? 11. Are you currently experiencing any swollen, red or warm areas on your body? 12. Do you have deep vein thrombosis? 13. Do you have any broken skin/skin problems blisters/sensitivities?
13. Are you taking any medication?*

Yes (fill in text box below 13a.)No (move into Question 14).
13a. If yes, please list what it is and what it's for -
14. What is your gender?

FemaleMalePrefer not to sayOther
15. Do you have any ALLERGIES, INJURIES, CONDITIONS or had any recent SURGERIES? (within last 5-10 years).*

Yes (please list below in Qu. 15a).No (I have had no injuries, allergies or surgeries within last 5-10 years).
15a. If yes, please list all relevant below:
PLEASE PROVIDE THE YEAR & INDICATE BODY ORIENTATION i.e. Left Hand Side, Right Hand Side.
16. Please describe your optimal treatment outcome for your upcoming therapy at Broulee Massage.
THIS FIELD IS OPTIONAL.
16a. Do you require any of the below? (This helps us ensure the table is set correctly for you on arrival):*

Breast Eez Support Pillow (helpful for clients with: breast implants, general breast tenderness, large breasts or breastfeeding).Pelvic Support Pillow (lower back pain/postural dip, anterior pelvic support).None (I do not require any additional bolsters apart from the usual ankle/knee/face support).
17. Do you have any additional disease(s), condition(s), older injuries or current problems that you feel we should know about before your treatment?*
TREATMENT CONSENT

Please read the disclaimer thoroughly.
I, (please print/type your full name): *
I understand that there may be an associated risk with any therapeutic intervention. I understand this is a massage clinic and not a medical practice and that a consultation process reviewing my health history is required before treatment begins. Please note: your therapist is sensitive to cigarette smoke and perfumes/colognes - please refrain from having a cigarette at least 2 hours before treatment and regarding personal hygiene a basic underarm deodorant is more suitable over perfumes/colognes. I understand that the therapist will determine a therapeutic strategy that is appropriate to my needs and also within the bounds of the practitioners scope of practice. The practitioner will explain the proposed therapeutic strategy and treatment plan to me and my consent to this plan will also be sought verbally. Instructions about the massage procedures, areas of the body being treated, draping, positioning on bed and undressing procedures will aim to be discussed in consultation prior to the therapist leaving the treatment room to provide privacy to the client before commencing treatment. I understand that I can request adaptations to the pressure of any massage techniques being applied during any stage of the treatment. I understand that it is best practice that pregnancy and oncology massage pressure application in the treatment will range from light – medium (4 – 5 / 10) and that there are acupressure points on the body that my therapist will need to avoid as best practice regarding my pregnancy. I understand that the guidelines for Pregnancy Massage in Australia deem that it is best practice for a professional Prenatal Massage to be performed in a side-lying position from 10 weeks gestation. I understand for oncology massage there is a possibility (unlikely) of slight bruising and 1-2 days of muscular discomfort or fatigue after the treatment. I have been encouraged to drink plenty of water over the next few days in order to avoid the possibility of post massage headache or nausea.Confidentiality is respected and at no time is any information received from me during the massage session given to any other person, except with my express permission.There may be risks of infection that occur between practitioners and their clients. These risks cannot be eliminated due to incubation periods that prevent people from knowing their infectious status. Infection control strategies are in place to protect both clients and practitioners in this clinic. I understand if I have any questions that I can ask my therapist/practitioner. I understand that there are some risks with any form of care. I understand that I will honestly discuss any risks with my practitioner and that I will be given the opportunity to ask questions beforehand and ensure that I am satisfied with the answers before commencing treatment. I understand that I can choose to cease treatment at any time. I understand that my therapist can choose to cease treatment at any time deemed any inappropriate behavior from the client. I understand that Broulee Massage is not a sexual service. I understand that my therapist has the right to cease treatment if they suspect that I am under the influence of illicit Drugs or Alcohol at the time of the treatment. I grant permission for a therapist from Broulee Massage to perform a treatment on me.
Yes, I do consent to the above information:*

Yes.
Signature*

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CLIENT INTAKE FORM

PLEASE READ:

MEDICAL HISTORY

TREATMENT CONSENT