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Massage Registration Form

Client Details

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What brings you to Epic Win PT?

What is the main problem you would like help with? What prompted this visit?

Have you been given a diagnosis for this problem? If yes, please state

Do you require clearance your doctor if you have any medical conditions?

Do you frequently feel stressed?:

Do you suffer from frequent headaches?

Do you suffer from any contagious diseases?:

Do you have any numbness of tingling?

Do you suffer from epilepsy or any form of seizures?:

Do you have any allergies?

If yes, please provide further detail

Have you suffered any accident or injuries in the last 2yrs?

If yes, please provide further detail

Are you taking any medications?

If yes, please what sort and what for?

Have you had any surgery that we should be aware of?

If yes, please explain:

Do you consume Alcohol?

If yes, what would be the frequency?

Do you smoke?

If yes, How many per day?

Have you had any previous bone breaks or fractures?

If yes, where and what date?

What do you consider to be your number one priority?

Name two areas of your life which you are not happy with right now and would like to improve

Medical Background

DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING

Palpitations/Chest Pain Heart Condition Stroke Low or High Blood Pressure Blood Disorder Diabetes Liver/Kidney Conditions Stomach/Duodenal Ulcer Infectious Disease Currently Pregnant Epilepsy Lipoma(s) Varicose Veins Cancer Spinal Injury

If you have ticked any of the above, a medical clearance from your doctor or specialist may be required prior to commencing your exercise program in the interest of your personal safety.

Is there a family history of any of the above conditions? If so, please list them

Have you had any illnesses in the last 12 months? If YES, please give details

Do you have any allergies?

Do you have Arthritis, Asthma or Hernia?

Are you receiving any treatment from a doctor, physiotherapist or other health professional? If Yes - What for?

Have you been hospitalized recently or given birth in the last 3 months?

Do you have any aches, pains, niggles or injuries to the following:

NECK:

If YES, Please elaborate

BACK:

If YES, Please elaborate

SHOULDERS:

If YES, Please elaborate

HIPS:

If YES, Please elaborate

KNEES:

If YES, Please elaborate

ANKLES:

If YES, Please elaborate

FEET:

If YES, Please elaborate

Do you have any other medical problems or conditions we should know about prior to commencing a massage treatment?

Do you agree to these terms and conditions?

Unit 2/8 Finsbury Street, NEWMARKET QLD 4051

Phone: 0412 522 792

Email: info@epicwinpt.com.au

Mon-Fri: 5:00am – 9:00pm

Sat: Closed

Sun: 2pm – 6pm

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