» Zulu

I understand the Massage services are designed to be a Health aid and are in no way to take the place of a Doctors or Physiotherapist’s care.

Name *

Date of birth *

Preferred name

Address

Referred by

Email *

Phone Number (Home) *

Phone Number (Work)

Emergency contact *

General Practitioner's Phone

Hand Dominant *

Left handed

Right handed

Occupation

Sports Interests

Reason for appointment / session goals:

Medical History

Do you have any restrictions in movement during everyday tasks? If yes, please outline

Are you currently under the care of a health professional? And if so, whom (and contact details)?

Do we have permission to contact the above listed health professional if it is considered relevant to your treatment?

Yes

No

How would you describe your general health?

Description and date of Past Injuries/Operations/Conditions

Recent Injuries: (within 12 months)

Current Medications (please include the dose and frequency)

Please specify

Do you have difficulty lying on your back/front/side

Previous massage experience/treatment

Please Identify Specific Areas Of Soreness

Please indicate if any of the following relate to you? Tick where yes

General

General area

Head / Neck

Shoulders and Arms

Pain

Stiffness

Dislocations

Frozen Shoulder

Elbow Problem

RSI / OOS

Carpal tunnel syndrome

Weakness of grip

Strains and sprains

Chest / Abdomen

Hips and Legs

Other

Tick for signature *