Health History Form Please complete 24hours prior to your booking. Name * First Name Last Name Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Date of Birth * MM DD YYYY Occupation Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### What areas do you feel discomfort? What aggravates or limits your activity? What alleviates or improves your activity? Please list any sports/recreational activities you participate in and how often? Past Injuries/surgery? Do you have any allergies? On most occasions, massage is beneficial. Sometimes it may not be appropriate or may need to be modified to best suit the individual. Please tick the relevant boxes if you have had any of the following. Arthritis Asthma Back pain/spinal problems Broken bones/Fracture Cancer Cardiac/circularly condition Coronavirus Depression/Stress/anxiety Heart Condition/High/Low blood pressure Headaches/Whiplash Inflammation Metal implants/pacemaker Loss of balance/dizziness/vertigo Numbness/tingling/stabbing pain Osteoporosis Seizures Skin condition/area of broken skin Sprain/bruises Other COVID-19 * I understand that because massage involves touch and close physical proximity over an extended period of time there may be an elevated risk of disease transmission, including COVID-19. The therapist has explained the risks to me and I consent to receive massage. I also consent to have my contact information shared with the relevant government authorities in the event that contact tracing is required. Please indicate if you are currently experiencing any of the following symptoms * Fever Dry cough or sore throat Runny nose Unexplained muscle or joint pain Headache Excessive tiredness Shortness of breath Loss of smell/tasted Upset stomach/diarrhoea Loss of appetite None of the above Have you or any of your close contacts experienced any of the above symptoms in the last 14 days? Yes No Have you or any of your close contacts been near anyone diagnosed positive for COVID-19 in the last 14 days? * Yes No Have you or any of your close contacts travelled interstate, overseas or regionally to an identified COVID-19 'hotspot' in the last 14 days? * Yes No * I understand that the massage I receive is provided for the basic purpose of managing pain, discomfort, muscular dysfunction and stress management. * If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or technique may be adjusted to my level of comfort. * I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose and prescribe and that nothing said in the course of the session given should be construed as such, and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. * Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known 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 therapists part should I fail to do so. How did you hear about me? * Friend/Family Referral - Other Google Search Social Media Online - Other Brochure This Week Magazine Other Client Signature (Type Name) * Date * MM DD YYYY Thank you!
