Client Details
First Name
Last Name
Date Of Birth
Street Address
Suburb
Postcode
Contact Number
Email
Occupation
Have you had a massage before?
Where did you hear about Epic Win PT?
Emergency Contact
Name
Contact Number
Relationship
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:
If yes, what would be the frequency?
Daily
A couple of times through the week
On Weekends
Maybe once a month
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
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:
If YES, Please elaborate
If YES, Please elaborate
If YES, Please elaborate
If YES, Please elaborate
If YES, Please elaborate
If YES, Please elaborate
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?
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