Remedial Therapy Intake Form

*** MOBILE + TABLET USERS ***

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All information provided will be kept confidential unless required by law.
At no given point is information disclosed or shared without a client's written consent.
Bold titles below with a red asterisk * are required to have information typed into the relevant box. If you have attempted to submit your form and you get "There are errors on the form......", you need to scroll up to the highlighted field to complete before clicking on the submit form button again.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postcode
Date of Birth*

DayMonthYear
Phone Number*
E-mail*

Confirmation Email
Occupation*
Family or friend to contact in case of emergency at your appointment*
How Did You Find Us?*

WebsiteFacebookInstagramFamilyFriendOnline SearchOther

Select Conditions Past & Now

	Past	Now
High blood pressure
Low blood pressure
Heart condition or blood disorder
Pacemaker
Asthma or respiratory condition
Fibromyalgia or chronic fatigue
Headaches or migraines
Surgery or hospitalisations
Digestive or bowel conditions (IBS,reflux,Crohn's)
Depression/anxiety/stress disorders
Bone fractures or joint dislocations
Skin conditions (dermatitis,psoriasis)
Arthritis or other joint conditions
Infections or contagious conditions
Allergies (fragrances,oils, lotions)
For women: pregnancies
For woman: menstrual disorders
Other conditions not listed above (describe below)

Explain further the marked conditions, disorders, injuries &/or surgeries that you ticked in the boxes above.
Are you taking any of the following?

Nerve medsPain medsAnti-inflammatoriesMuscle relaxantsInsulinBlood thinnersOther (type other meds below)
Medications - prescribed & over the counter, including dosage
Explain what the medications listed above are for
Have you had a massage before?

Yes, occasionallyYes, regularlyWhen neededNo, never
What type of therapy are you seeking?
Reason for seeking therapy?
Massage pressure preference

LightMediumFirmI want to relaxWhatever is needed for relieving pain

Select the boxes where your discomfort, pain or stiffness is? (If filling the below form on a device, tap and hold the screen to move left & right to select relevant boxes)

	Left Side	Right Side	Muscle	Joint	Pain or Ache	Shooting Pain	Sharp Pain	Numb & Tingling	Stiffness
Head
Neck
Shoulder
Upper Back
Middle Back
Low Back
Glutes/Buttocks
Hip
Knee
Ankle
Wrist
Elbow
Forearm
Chest
Abdomen
Thighs
Hamstrings
Calves

Rate Your Pain

0

1

2

3

4

5

6

7

8

9

10

0 is No Pain, 10 is Worst Pain
Rate Your Fatigue

0

1

2

3

4

5

6

7

8

9

10

0 is No fatigue, 10 is Exhausted, confined to bed
At what time of day is the pain at its worse?

MorningAfternoonEveningDuring SleepOther
Frequency

ConstantOff/OnAt RestWith/During/After ActivityOther
How long have you been experiencing this pain/discomfort?
How many days - week - months - years?
What aggravates your pain?
What eases your pain?
Are there any areas (feet, face, abdomen etc.) you don't want massaged?

NoYes
If yes to an area you don't want massaged please explain below
Are you currently seeing any of the following?

General PractitionerPhysiotherapistChiropractorAcupuncturistNaturopathOsteopathSpecialistOther
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

• Your scheduled session is set aside for you. We do not double book appointments

• Please reschedule your session if you are more than 15 minutes late

• 24+ hour cancellation notice is required to avoid being charged for your session

• You will be draped and at no time will genitalia or breast tissue be exposed

• You will have a consultation with your therapist to discuss your session

• Should the session require, after your therapist has left the room, you may disrobe to your comfort level

• I understand that my Massage Therapist or I may end the session at any time for any reason

• Inappropriate behaviour will not be tolerated and may be prosecuted to the full extent of the law
I have provided all my known medical information. I acknowledge that massage therapy is not a substitute for medical diagnosis and treatment. I consent to receive treatment.

By my electronic signature below, I agree to the treatment policy and client agreement above.
Select Today's Date*
Digital Signature*

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