Name * First Name Last Name Date of Birth * MM DD YYYY Address * Contact Telephone Number * Email * Emergency Contact Name * Emergency Contact Relationship to You * Emergency Contact Number * Name & Address of HP * How did you hear about me? Recommendation Web Facebook Referral Other Do you suffer from, or have you ever suffered from any of the following; Thyroid problems Heart conditions Rheumatoid arthritis (or other inflammatory conditions) Epilepsy Asthma (or other respiratory problems) Diabetes Steroid use Blood pressure issues Skin infections/conditions/varicose veins Stroke Thrombosis/phlebitis Cancer Recent surgery Digestive problems Headaches Allergies Anxiety/depression/stress Burstitis Injuries/spasms/cramps/sprains or strains Fibromyalgia Oedema Headaches Neuropathy Are there any conditions that run in your family? Yes No Are you pregnant? No Yes Are you going through the menopause? No Yes Please give details of any of the above including regular medicines you are taking: Is there anything else about your health or wellbeing you would like to tell me about? What brings you here to see me today? What do you hope to achieve and how long do you think this might take? How would you like me to help work towards your goals? Please advise of any areas where you are currently experiencing pain. If there are multiple areas, please list them in terms of priority. Can you describe how these areas feel? Where are you on the pain scale from 0-10? 0 being no pain at all to 10 being the worst possible pain> 1 2 3 4 5 6 7 8 9 10 Can you describe how it makes you feel and how it affects your daily life? When did you first notice it? Describe what it's like to live with over 24 hours; Have you noticed any things that make it feel worse? What have you tried already to make it feel better? and has anything helped at all? What things that are important to you is it stopping you from doing or making it hard for you to do? Are there any things you are still managing despite it? What is your job? What physical activities or sports do you do? and how often? How has your mood been recently? How are your stress levels on a scale of 0-10? 0 being completely relaxed and 10 being highly stressed? 0 1 2 3 4 5 6 7 8 9 10 What is your favourite way of winding down and relaxing? How is your sleep? Good Fair Poor Do you struggle to get off to sleep? Are you too busy to get enough? Do you wake up feeling refreshed? Does pain keep you awake or wake you? How many hours on average do you think you sleep at night? How do you feel your diet is generally? Good Fair Poor GDPR Data Privacy Notice I take your privacy seriously, and will treat your data as you would expect, and will never sell, share or otherwise abuse your data. Your details will be stored for up to 7 years after your last visit. DISCLAIMER I understand my massage therapist is not medically trained, cannot diagnose or treat illness and disease. I understand the treatment offers many benefits, but these are not guaranteed. I understand I will have to remove clothing for the treatment to be carried out, and oil will be applied to my skin. If any pain is experienced during session(s) I will immediately inform my therapist so that work can be adjusted to my level of comfort. I confirm the information above is correct to the best of my ability, and I will inform my therapist of any future changes. Thank you! IF YOU WOULD PREFER TO PRINT, COMPLETE & RETURN THE FORM TO ME AT YOUR APPOINTMENT YOU CAN DOWNLOAD IT HERE:
