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Massage Client Case History and Consent Form
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Massage Client Case History and Consent Form
Massage Form
First name
*
Last name
*
Preferred name
Title
*
Mr
Mrs
Miss
Ms
Mstr
Other
Other
Date of birth (dd/mm/yyyy)
Address
*
Address
Address
Address
Suburb
Suburb
State
State
Postcode
Postcode
Email
Home
Work
Mobile
Occupation
Private health insurer
Who can we thank for referring you to us?
Are you happy to receive SMS reminders for upcoming appointments?
Yes
No
We send out a monthly newsletter, do you wish to receive this?
Yes
No
How long since your last massage?
Do you
currently
suffer from any of the following conditions:
Spinal/back problems
Headaches
Asthma
High/low blood pressure
Osteoporosis
Varicose Veins
Cancer
Surgery in past 12 months
Bruising
Allergies
Heart condition
Joint injury
Arthritis
Haemophilia
Immune deficiency
Skin disorder
Numbness/tingling
Diabetes
Epilepsy
Recent bone fracture
Enlarged lymph nodes
Thrombosis
An infectious condition
Have you suffered
in the past
from any of the following conditions:
Spinal/back problems
Headaches
Asthma
High/low blood pressure
Osteoporosis
Varicose Veins
Cancer
Surgery in past 12 months
Bruising
Allergies
Heart condition
Joint injury
Arthritis
Haemophilia
Immune deficiency
Skin disorder
Numbness/tingling
Diabetes
Epilepsy
Recent bone fracture
Enlarged lymph nodes
Thrombosis
An infectious condition
Are there any other conditions that I should be aware of?
Yes
No
If yes, please provide details:
*
Please provide details of any other treatment you’ve had (eg: acupuncture/chiro/physio)
Are there any medications you are currently taking?
Are you pregnant or likely to be pregnant?
*
No
Yes (how many weeks?)
Yes (how many weeks?)
Reason for visit/presenting complaint
Please put an (X) on any areas of concern for treatment today
Clear
Remedial Massage may include face, head, chest, stomach, back, buttocks, arms, legs and feet depending on the area of the problem.
Please indicate any area you would
not
like to have included in the massage
Remedial Massage therapy is provided for stress reduction, relief from muscular tension, improvement in postural function and improvement of circulation and energy flow.
Remedial Massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat physical or mental illness. If you are in doubt, consult your medical practitioner.
If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/ strokes can be adjusted to my level of comfort. I understand that Remedial Therapy involves deep soft-tissue work, and depending on the severity of the problem it is normal to feel some muscle soreness and tenderness within the days following the treatment.
I affirm that I have notified my therapist of all known medical history and I agree to inform the therapist of any changes in my health and any medical condition.
I give consent, by signing below, to cover the entire course of treatment for my presenting complaint(s), and for any other future condition(s) for which I seek treatment from the below named Remedial Masseuse and any of the registered Practitioners practicing at Noosa Chiropractic and Skin Health Noosa.
I have read, or have had read to me the above consent and I have also had an opportunity to ask questions about this content.
Client's signature
*
Clear
Client's name
*
Date (dd/mm/yyyy)
*
Chiropractor's signature
Clear
Chiropractor's name
Date (dd/mm/yyyy)
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