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Confidential Client History Form Remedial Treatment
Contact Details*
Date of Birth*
Email*
Contact Number*
Emergency Contact Details*
Previous Massage Treatment*
yes
no
Dr's Name
Dr's Contact Details
Other Allied Health Professional
Contact Details
GENERAL HEALTH SCREEN
Weight*
Height*
LIFESTYLE HABITS
Alcohol consumption (glasses/week)
Eating habits
Emotions
Water consumption (glasses/day)
Smoker (#/day)
Sleeping patterns
Leisure activities/level of exercise
Type of Employment and Work Habits
Previous Diagnostic / Surgical / Illness / Accidents
none
X-rays/investigations
Operations
Illnesses
Accidents
Other injuries
Detail
Health History
Please tick all conditions that apply now.
Abdominal or digestive
problems
Fibromyalgia
Muscle, bone injuries
Allergies
Headaches or migraines
Numbness or tingling
Arthritis Hearing problems Phlebitis
Asthma or lung
conditions
Heart, circulatory
problems
Pregnancy
Blood clots Hernias Rash, athletes foot/tinea
Cancer / Tumors High / Low blood
pressure
Seizures
Chronic Fatigue Infectious disease Skin disorders
Chronic pain Lymph node removal Stroke
Depression Motor vehicle accident /
trauma
Varicose veins
Diabetes Muscle or joint pain Vision problems or contact lenses
Fatigue Other (to be filled by practitioner
Other conditions not listed above
Current medications
(including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies)
Recent surgeries and dates of surgery
Current symptoms
(location and duration or onset)
History of presenting complaint
(how it happened - position / direction etc)
Behaviour of and type of pain
(constant / with movement / with activity / sharp / shooting / dull / aching etc)
Aggravating factors
(activities / posture / stressors)
Relieving factors
(movement/rest/posture/heat/cold)
Previous Treatments
(include all health care types – Complementary Medicine Practitioner and / or Medical Doctor, Physiotherapist, Osteopath, Chiropractor, Dentist)
Results
Please indicate from the diagram below, the area that are affected or that are painful.
A1
A2
A3
A4
A5
A6
A7
B1
B2
B3
B4
B5
B6
B7
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
D1
D2
D3
D4
D5
D6
D7
D8
D9
Only sign below if the above information is understood and has occurred
Clients Name*
Date
Signature*
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