Massage Registration Form

Client Details

First Name

Gender

Last Name

Date Of Birth

Street Address

Suburb

Postcode

Contact Number

Occupation

Have you received a massage before?

Where did you hear about Epic Win PT?

Medical Contact Information

Doctor's Name

Contact Number

Practice/Clinic Name

Emergency Contact

Name

Contact Number

Relationship

GENERAL INFORMATION

Please take a moment to carefully read the following information. If you have a specific medical condition, or specific symptoms, massage may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

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

Yes No

Do you frequently feel stressed?

Yes No

Do you suffer from frequent headaches?

Yes No

Do you suffer from any contagious diseases?

Yes No

Do you have any numbness of tingling?

Yes No

Do you suffer from epilepsy or any form of seizures?

Yes No

Do you have any allergies?

Yes No

If yes, please provide further detail:

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

Yes No

If so,explain:

Are you taking any medications?

Yes No

If yes, what sort and what for?

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

Yes No

If so, explain:

Do you consume Alcohol?

Yes No

If so, How often?

Do you smoke?

Yes No

If so, how many per day:

Have you had any previous bone breaks or fractures?

Yes No

If so, where and what date?

Have you experiences any of the following conditions?

If any of the above ticked, please provide further information regarding date of diagnosis, treatment etc

Are you currently pregnant?

Yes No

Do you have any other medical conditions we should know about?

Yes No

If so, please provide further information

HISTORY OF CURRENT COMPLAINTS, PROBLEMS

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:

Yes No

Is this problem interfering with any of the listed aspects of your life? If so, please explain

OTHER:

The following responses are considered a normal response to relaxation and/or touch which sometimes occurs during a treatment. You need not be embarrassed nor suppress them: Movement or release of intestinal gas – crying – laughing – strong emotions – sighing – groaning – yawning – softening of muscle tissue – cognitive or felt memories – stomach gurgling – the need to move or change position.

CLIENT CONSENT

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to a level of comfort. I understand that the massage therapist is not qualified to perform spinal or skeletal adjustments, diagnose or prescribe, or treat any physical or mental illness. I affirm that I have stated all my medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. I acknowledge that the therapist will only work within their scope of practice. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment.

CLIENT ACCEPTANCE

I AGREE

As wonderful as massage is to relax and pamper or perhaps treat yourself to something special, there is also another important factor that people forget. It is also a lifestyle change. The only way we can reap all the benefits of massage is to also make sure that our lifestyles match. Activities in our daily lives such as exercise and diet are just as important as our rest and recreational activities. We must look after all aspect of our lives including our physical, mental, emotional and spiritual growth, in order to find a healthy balance in life.

Client Details

Medical Contact Information

Emergency Contact

GENERAL INFORMATION

Have you experiences any of the following conditions?

HISTORY OF CURRENT COMPLAINTS, PROBLEMS

CLIENT CONSENT

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