Client History

If possible please complete the below Client History form before your first appointment - this will allow me to focus on the areas of importance and maximise your treatment time. All information is confidential. Feel free to add as much detail as you feel is relevant and if you are unsure about anything don't hesitate to ask me.

client details

* Indicates required field

Name *

First

Last

Gender *

D.O.B. *

Address *

Mobile no. *

Email *

Emergency contact: Name, relationship & no. *

How did you hear about me? *

general information

Occupation *

Sports, activities (and how often) *

Other modalities (e.g. chiro, osteo, naturopath, other massage therapist) *

history

Past surgery (if so, how long ago) *

Major illnesses, past or present *

Major injuries or falls (if so, how long ago) *

Medication or recreational drugs *

Allergies (esp. nuts) *

Skin conditions *

Blood pressure *

Smoking habits *

How would you describe your general health? (diet, sleep, exercise, stress levels, immunity) *

Comments *

Submit