Rehab Hive Consultation Form

Rehab Hive Consultation Form

This intake form helps us understand your needs, ensures clarity, and builds confidence in your treatment. All information is confidential. Please complete it as accurately as possible so your session can be safe, personalised, and effective.
Full Name

First NameLast Name
What is your age?
What is your gender?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Check the conditions that apply to you or any member of your immediate relatives:

Other
Check the symptoms that you' re currently experiencing:

Other
Do you have any medication allergies?
Are you currently taking any medication?
Please list them.
Do you smoke?
This includes tobacco, cannabis, and any other recreational or legal substances. Please answer honestly to ensure safe and effective treatment.
How often do you consume alcohol?
Reason for Booking / Areas of Concern
Please describe in detail why you are booking this session. Include any symptoms, pain points, or areas of concern you’d like addressed. The more information you provide, the better we can tailor your treatment.
Pain Scale/ Severity 1-10
Have you received any previous treatments related to your current concern?
Have you received any previous treatments related to your current concern?
What are your goals for this session?
Please describe what you hope to achieve (e.g., pain relief, improved mobility, relaxation, rehabilitation support).
Is there anything about your home environment I should be aware of before arrival?
Please mention details such as stairs, parking restrictions, pets, limited space, or anything else that may affect setup or safety.
Emergency Contact

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
By submitting this form, you confirm that all information provided is true, complete, and accurate to the best of your knowledge. You understand that your treatment plan is based on the details you share, and any withheld or inaccurate information may affect your care. You acknowledge that this consultation or treatment does not replace medical advice from a GP or other healthcare professional. Please also note that I will be bringing a massage couch approximately 180 cm (under 6 ft) in length. Ensure there is enough clear space for safe setup and treatment.
Signature
Should be Empty: