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Astrology
Coaching and Mentorship
Sky Gazing
Podcast
Shop
Kind words
Connect
Lets share the adventure...
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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!
