{"id":4886,"date":"2022-04-07T20:00:36","date_gmt":"2022-04-07T13:00:36","guid":{"rendered":"https:\/\/waneethai.com\/?page_id=4886"},"modified":"2022-04-07T20:03:26","modified_gmt":"2022-04-07T13:03:26","slug":"confidential-client-history-form-remedial-treatment","status":"publish","type":"page","link":"https:\/\/waneethai.com\/confidential-client-history-form-remedial-treatment\/","title":{"rendered":"Confidential Client History Form Remedial Treatment"},"content":{"rendered":"[vc_row type=&#8221;full_width_content&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#f1ac4e&#8221; bg_image=&#8221;3166&#8243; bg_position=&#8221;center top&#8221; background_image_loading=&#8221;default&#8221; bg_repeat=&#8221;no-repeat&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;6%&#8221; bottom_padding=&#8221;3%&#8221; text_color=&#8221;light&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_spacing=&#8221;default&#8221; centered_text=&#8221;true&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221;][vc_column_text]\n<h3>Confidential Client History Form Remedial Treatment<\/h3>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#ffffff&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;3%&#8221; bottom_padding=&#8221;3%&#8221; text_color=&#8221;dark&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; advanced_gradient_angle=&#8221;0&#8243; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221; gradient_type=&#8221;default&#8221; shape_type=&#8221;&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_spacing=&#8221;default&#8221; background_color_opacity=&#8221;1&#8243; background_hover_color_opacity=&#8221;1&#8243; column_shadow=&#8221;none&#8221; column_border_radius=&#8221;none&#8221; column_link_target=&#8221;_self&#8221; column_position=&#8221;default&#8221; advanced_gradient_angle=&#8221;0&#8243; gradient_direction=&#8221;left_to_right&#8221; overlay_strength=&#8221;0.3&#8243; width=&#8221;1\/1&#8243; tablet_width_inherit=&#8221;default&#8221; tablet_text_alignment=&#8221;default&#8221; phone_text_alignment=&#8221;default&#8221; animation_type=&#8221;default&#8221; bg_image_animation=&#8221;none&#8221; border_type=&#8221;simple&#8221; column_border_width=&#8221;none&#8221; column_border_style=&#8221;solid&#8221; gradient_type=&#8221;default&#8221;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f4885-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/4886#wpcf7-f4885-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"4885\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f4885-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Contact Details*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-contact-detail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-contact-detail\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Date of Birth*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-birth-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-birth-date\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Email*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Contact Number*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-phone\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-phone\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Emergency Contact Details*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-emergency-contact-detail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-emergency-contact-detail\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Previous Massage Treatment*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-massage-treatement\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"your-previous-massage-treatement\" value=\"yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"your-previous-massage-treatement\" value=\"no\" \/><span class=\"wpcf7-list-item-label\">no<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Dr's Name<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-dr-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-dr-name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Dr's Contact Details<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-dr-contact-detail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-dr-contact-detail\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Other Allied Health Professional<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-other-allied-health-professional\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-other-allied-health-professional\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Contact Details<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-other-allied-contact-detail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-other-allied-contact-detail\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"margin:60px 0px;\">\n\t<h4>GENERAL HEALTH SCREEN\n\t<\/h4>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Weight*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-weight\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-weight\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:48%; float:left; margin-bottom:20px;\">\n\t<p><label>Height*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-height\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-height\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"margin:60px 0px; clear:both;\">\n\t<h4>LIFESTYLE HABITS\n\t<\/h4>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Alcohol consumption (glasses\/week)<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-alcohol-consumption\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-alcohol-consumption\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Eating habits<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-eating-habits\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-eating-habits\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Emotions<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-emotions\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-emotions\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Water consumption (glasses\/day)<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-water-consumption\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-water-consumption\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Smoker (#\/day)<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-smoker\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-smoker\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:48%; margin-right:1%; float:left; margin-bottom:20px;\">\n\t<p><label>Sleeping patterns<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-sleeping-patterns\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-sleeping-patterns\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Leisure activities\/level of exercise<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-leisure-activities\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-leisure-activities\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Type of Employment and Work Habits<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-work-habits\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-work-habits\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"margin:60px 0px;\">\n\t<h4>Previous Diagnostic \/ Surgical \/ Illness \/ Accidents\n\t<\/h4>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-diagnostic\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-previous-diagnostic[]\" value=\"none\" \/><span class=\"wpcf7-list-item-label\">none<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-previous-diagnostic[]\" value=\"X-rays\/investigations\" \/><span class=\"wpcf7-list-item-label\">X-rays\/investigations<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-previous-diagnostic[]\" value=\"Operations\" \/><span class=\"wpcf7-list-item-label\">Operations<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-previous-diagnostic[]\" value=\"Illnesses\" \/><span class=\"wpcf7-list-item-label\">Illnesses<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-previous-diagnostic[]\" value=\"Accidents\" \/><span class=\"wpcf7-list-item-label\">Accidents<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-previous-diagnostic[]\" value=\"Other injuries\" \/><span class=\"wpcf7-list-item-label\">Other injuries<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Detail<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-diagnostic-detail\"><textarea cols=\"40\" rows=\"2\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-previous-diagnostic-detail\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<div style=\"margin:60px 0px;\">\n\t<h4>Health History\n\t<\/h4>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Please tick all conditions that apply now.<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-health-history\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Abdominal or digestive\" \/><span class=\"wpcf7-list-item-label\">Abdominal or digestive<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"problems\" \/><span class=\"wpcf7-list-item-label\">problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Fibromyalgia\" \/><span class=\"wpcf7-list-item-label\">Fibromyalgia<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Muscle, bone injuries\" \/><span class=\"wpcf7-list-item-label\">Muscle, bone injuries<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Allergies\" \/><span class=\"wpcf7-list-item-label\">Allergies<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Headaches or migraines\" \/><span class=\"wpcf7-list-item-label\">Headaches or migraines<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Numbness or tingling\" \/><span class=\"wpcf7-list-item-label\">Numbness or tingling<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Arthritis Hearing problems Phlebitis\" \/><span class=\"wpcf7-list-item-label\">Arthritis Hearing problems Phlebitis<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Asthma or lung\" \/><span class=\"wpcf7-list-item-label\">Asthma or lung<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"conditions\" \/><span class=\"wpcf7-list-item-label\">conditions<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Heart, circulatory\" \/><span class=\"wpcf7-list-item-label\">Heart, circulatory<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"problems\" \/><span class=\"wpcf7-list-item-label\">problems<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Pregnancy\" \/><span class=\"wpcf7-list-item-label\">Pregnancy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Blood clots Hernias Rash, athletes foot\/tinea\" \/><span class=\"wpcf7-list-item-label\">Blood clots Hernias Rash, athletes foot\/tinea<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Cancer \/ Tumors High \/ Low blood\" \/><span class=\"wpcf7-list-item-label\">Cancer \/ Tumors High \/ Low blood<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"pressure\" \/><span class=\"wpcf7-list-item-label\">pressure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Seizures\" \/><span class=\"wpcf7-list-item-label\">Seizures<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Chronic Fatigue Infectious disease Skin disorders\" \/><span class=\"wpcf7-list-item-label\">Chronic Fatigue Infectious disease Skin disorders<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Chronic pain Lymph node removal Stroke\" \/><span class=\"wpcf7-list-item-label\">Chronic pain Lymph node removal Stroke<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Depression Motor vehicle accident \/\" \/><span class=\"wpcf7-list-item-label\">Depression Motor vehicle accident \/<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"trauma\" \/><span class=\"wpcf7-list-item-label\">trauma<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Varicose veins\" \/><span class=\"wpcf7-list-item-label\">Varicose veins<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Diabetes Muscle or joint pain Vision problems or contact lenses\" \/><span class=\"wpcf7-list-item-label\">Diabetes Muscle or joint pain Vision problems or contact lenses<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-health-history[]\" value=\"Fatigue Other (to be filled by practitioner\" \/><span class=\"wpcf7-list-item-label\">Fatigue Other (to be filled by practitioner<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Other conditions not listed above<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-other-conditions-detail\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-other-conditions-detail\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Current medications<\/label><br \/>\n(including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-current-medications\"><textarea cols=\"40\" rows=\"2\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-current-medications\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Recent surgeries and dates of surgery<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-recent-surgeries\"><textarea cols=\"40\" rows=\"2\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-recent-surgeries\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Current symptoms<\/label><br \/>\n(location and duration or onset)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-current-symptoms\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-current-symptoms\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>History of presenting complaint<\/label><br \/>\n(how it happened - position \/ direction etc)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-history-presenting-complaint\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-history-presenting-complaint\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Behaviour of and type of pain<\/label><br \/>\n(constant \/ with movement \/ with activity \/ sharp \/ shooting \/ dull \/ aching etc)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-behaviour-pain\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-behaviour-pain\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Aggravating factors<\/label><br \/>\n(activities \/ posture \/ stressors)\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-aggravating-factors\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-aggravating-factors\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Relieving factors<\/label><br \/>\n(movement\/rest\/posture\/heat\/cold)\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-relieving-factors\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-relieving-factors\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Previous Treatments<\/label><br \/>\n(include all health care types \u2013 Complementary Medicine Practitioner and \/ or Medical Doctor, Physiotherapist, Osteopath, Chiropractor, Dentist)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-treatments\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-previous-treatments\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Results<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-previous-treatments-results\"><textarea cols=\"40\" rows=\"2\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-previous-treatments-results\"><\/textarea><\/span>\n\t<\/p>\n<\/div>\n<div style=\"margin:60px 0px;\">\n\t<h5>Please indicate from the diagram below, the area that are affected or that are painful.\n\t<\/h5>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><img decoding=\"async\" src=\"https:\/\/waneethai.com\/wp-content\/uploads\/2022\/04\/Pic-Posture-01.jpg\" \/>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-pain-spot-a\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A1\" \/><span class=\"wpcf7-list-item-label\">A1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A2\" \/><span class=\"wpcf7-list-item-label\">A2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A3\" \/><span class=\"wpcf7-list-item-label\">A3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A4\" \/><span class=\"wpcf7-list-item-label\">A4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A5\" \/><span class=\"wpcf7-list-item-label\">A5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A6\" \/><span class=\"wpcf7-list-item-label\">A6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-pain-spot-a[]\" value=\"A7\" \/><span class=\"wpcf7-list-item-label\">A7<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-pain-spot-b\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B1\" \/><span class=\"wpcf7-list-item-label\">B1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B2\" \/><span class=\"wpcf7-list-item-label\">B2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B3\" \/><span class=\"wpcf7-list-item-label\">B3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B4\" \/><span class=\"wpcf7-list-item-label\">B4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B5\" \/><span class=\"wpcf7-list-item-label\">B5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B6\" \/><span class=\"wpcf7-list-item-label\">B6<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-pain-spot-b[]\" value=\"B7\" \/><span class=\"wpcf7-list-item-label\">B7<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-pain-spot-c\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C1\" \/><span class=\"wpcf7-list-item-label\">C1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C2\" \/><span class=\"wpcf7-list-item-label\">C2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C3\" \/><span class=\"wpcf7-list-item-label\">C3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C4\" \/><span class=\"wpcf7-list-item-label\">C4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C5\" \/><span class=\"wpcf7-list-item-label\">C5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C6\" \/><span class=\"wpcf7-list-item-label\">C6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C7\" \/><span class=\"wpcf7-list-item-label\">C7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C8\" \/><span class=\"wpcf7-list-item-label\">C8<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C9\" \/><span class=\"wpcf7-list-item-label\">C9<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-pain-spot-c[]\" value=\"C10\" \/><span class=\"wpcf7-list-item-label\">C10<\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-pain-spot-d\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D1\" \/><span class=\"wpcf7-list-item-label\">D1<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D2\" \/><span class=\"wpcf7-list-item-label\">D2<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D3\" \/><span class=\"wpcf7-list-item-label\">D3<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D4\" \/><span class=\"wpcf7-list-item-label\">D4<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D5\" \/><span class=\"wpcf7-list-item-label\">D5<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D6\" \/><span class=\"wpcf7-list-item-label\">D6<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D7\" \/><span class=\"wpcf7-list-item-label\">D7<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D8\" \/><span class=\"wpcf7-list-item-label\">D8<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"your-pain-spot-d[]\" value=\"D9\" \/><span class=\"wpcf7-list-item-label\">D9<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n<\/div>\n<div style=\"margin:20px 0px;\">\n\t<h5>Only sign below if the above information is understood and has occurred\n\t<\/h5>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Clients Name*<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-clients-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-clients-name\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px;\">\n\t<p><label>Date<\/label>\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-information-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"your-information-date\" \/><\/span>\n\t<\/p>\n<\/div>\n<div style=\"width:98%; margin:20px 0px; border: 1px solid #333; clear:both;\">\n\t<p><label>Signature*<\/label>\n\t<\/p>\n\t<div class=\"wpcf7-form-control-signature-global-wrap\" data-field-id=\"your-signature\">\n\t\t\t\t<div class=\"wpcf7-form-control-signature-wrap\" style=\"width:900px;height:200px;\">\n\t\t\t\t\t<div class=\"wpcf7-form-control-signature-body\">\n\t\t\t\t\t\t<canvas id=\"wpcf7_your-signature_signature\" class=\"your-signature\"><\/canvas>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"wpcf7-form-control-clear-wrap\">\n\t\t\t\t\t<input id=\"wpcf7_your-signature_clear\" type=\"button\" value=\"Clear\"\/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<span class=\"wpcf7-form-control-wrap wpcf7-form-control-signature-input-wrap your-signature\">\n\t\t\t\t<input aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"hidden\" name=\"your-signature\" id=\"wpcf7_input_your-signature\"\/><input type=\"hidden\" name=\"your-signature-attachment\" id=\"wpcf7_input_your-signature_attachment\"\/><input type=\"hidden\" name=\"your-signature-inline\" id=\"wpcf7_input_your-signature_inline\"\/>\n\t\t\t<\/span>\n\t\t\t\n\t<\/p>\n<\/div>\n<div>\n\t<div class=\"g-recaptcha-wrap\" style=\"padding:10px 0 10px 0\">\n\t\t<div  class=\"g-recaptcha\" data-sitekey=\"6LfJc8MpAAAAAEl3hyiZ2k9gnLGlxwIs6N2hNu5x\">\n\t\t<\/div>\n\t<\/div>\n\t<p><span class='wpcf7-form-control-wrap' data-name='aiowps-captcha'><\/span><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"63\"\/><script>document.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );<\/script><\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row][vc_row type=&#8221;full_width_background&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; 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background_image_loading=&#8221;default&#8221; bg_repeat=&#8221;no-repeat&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;6%&#8221; bottom_padding=&#8221;3%&#8221; text_color=&#8221;light&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221;][vc_column column_padding=&#8221;no-extra-padding&#8221; column_padding_tablet=&#8221;inherit&#8221; column_padding_phone=&#8221;inherit&#8221; column_padding_position=&#8221;all&#8221; column_element_spacing=&#8221;default&#8221;&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Confidential Client History Form Remedial Treatment - Wanee Thai Massage Therapy<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/waneethai.com\/confidential-client-history-form-remedial-treatment\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Confidential Client History Form Remedial Treatment - Wanee Thai Massage Therapy\" \/>\n<meta property=\"og:description\" content=\"[vc_row type=&#8221;full_width_content&#8221; full_screen_row_position=&#8221;middle&#8221; column_margin=&#8221;default&#8221; column_direction=&#8221;default&#8221; column_direction_tablet=&#8221;default&#8221; column_direction_phone=&#8221;default&#8221; bg_color=&#8221;#f1ac4e&#8221; bg_image=&#8221;3166&#8243; bg_position=&#8221;center top&#8221; background_image_loading=&#8221;default&#8221; bg_repeat=&#8221;no-repeat&#8221; scene_position=&#8221;center&#8221; top_padding=&#8221;6%&#8221; bottom_padding=&#8221;3%&#8221; text_color=&#8221;light&#8221; text_align=&#8221;left&#8221; row_border_radius=&#8221;none&#8221; row_border_radius_applies=&#8221;bg&#8221; overflow=&#8221;visible&#8221; overlay_strength=&#8221;0.3&#8243; gradient_direction=&#8221;left_to_right&#8221; shape_divider_position=&#8221;bottom&#8221; bg_image_animation=&#8221;none&#8221;][vc_column 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