Contact Details*

Date of Birth*

Email*

Contact Number*

Emergency Contact Details*

Previous Massage Treatment*
yesno

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

noneX-rays/investigationsOperationsIllnessesAccidentsOther injuries

Detail

Health History

Please tick all conditions that apply now.

Abdominal or digestiveproblemsFibromyalgiaMuscle, bone injuriesAllergiesHeadaches or migrainesNumbness or tinglingArthritis Hearing problems PhlebitisAsthma or lungconditionsHeart, circulatoryproblemsPregnancyBlood clots Hernias Rash, athletes foot/tineaCancer / Tumors High / Low bloodpressureSeizuresChronic Fatigue Infectious disease Skin disordersChronic pain Lymph node removal StrokeDepression Motor vehicle accident /traumaVaricose veinsDiabetes Muscle or joint pain Vision problems or contact lensesFatigue 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.

A1A2A3A4A5A6A7
B1B2B3B4B5B6B7
C1C2C3C4C5C6C7C8C9C10
D1D2D3D4D5D6D7D8D9

Only sign below if the above information is understood and has occurred

Clients Name*

Date

Signature*