New Client Intake Questionnaire

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If you're a new client, please take a minute to complete the following questions.

All information is treated with high confidence. Thank you.

Email *

Mobile *

First Name *

Last Name *

DOB (DD/MM/YY)

Emergency Contact (name and number)

Address (Suburb only)
*

Occupation

Why have you come for treatment?

How much exercise do you do each week?

Are you unwell today?

Yes

Are you pregnant?

Yes

Not Applicable

Do you have any allergies? (Leave Blank if NO)

Please check any of the following conditions or symptoms that apply to you:

High/low blood pressure

Diabetes

Epilepsy/seizures

Musculoskeletal conditions

Peripheral neuropathy

Skin conditions

Asthma

Osteoporosis

Recent injuries (explain below)

Recent illnesses (explain below)

Ongoing illness/injury (explain below)

Bruise easily

Prone to dizziness or fainting

Headaches/Migraines

Cancer (explain below)

Other:

If you ticked any of the above conditions, please provide any further relevant details:

Have you experienced any physical or psychological trauma that may impact on your treatment today?

Yes

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Additional Notes: (optional)

Lastly, how did you hear about us? *

Client Statement & Consent

I have completed this health form to the best of my knowledge. I understand that Massage and Stretch Therapy services are a therapeutic health aid and are non-sexual. I understand that massage and stretch therapy does not diagnose illness or disease and that the therapist does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of the therapy.

I understand that massage and stretch therapy are not substitutes for medical examination or medical care, and that it is recommended that I am concurrently working with my primary caregiver for any condition I may have. I agree to notify my therapist immediately if there is any change to my condition and will notify my therapist should I experience any pain or discomfort throughout treatment.

If I am unable to make the scheduled appointment, I agree to cancel at least 24 hours in advance unless in an emergency whereby I agree to contact the therapist ASAP to reschedule. I understand that If I do not give 24 hours notice, I agree to pay a cancellation fee of $40.

NB. If you are under 16 years old, a parent/guardian must attend your first appointment and must also give consent to treatment.

Agreement of Terms

By completing this form, you agree to our Terms and Conditions outlined on our website.

Send me a copy of my responses.

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