N & N Joseph , Health Questionnaire for Massage and Complementary Therapy

The following information is required for your safety and health. These details will be treated in the strictest of confidence. It may, however, be necessary for you to consult your GP before any treatment may be given.

Email address *

Contact Information: *

Name:

Your answer

Last Name:

Your answer

Mobile Number: *

Your answer

Date of Birth: *

YYYY

Home Address: *

Your answer

Postcode: *

Your answer

Occupation (Optional):

Your answer

Leisure pursuits: *

Your answer

How did you hear about N & N Joseph Massage Therapy? *

Website / Treatwell / google / Yelp / Referred/ Other – please list

Your answer

Medical History & Details:

Your answer

Have you or do you suffer from any of the following? (Please tick & give details where applicable) *

Dizziness/ Fainting/ Vertigo

Asthma

High Cholesterol

Emphysema

Shortness of Breath

Pacemaker

High Blood Pressure

Angina

Hernia (Type)

Low Blood Pressure

Stroke

Arthritis (Type) Rheumatoid, Osteo

Epilepsy/ Seizures

Option 14

Heart Disease

Osteopporosis/ Fracture

Diabetes

Headaches/ Migraines

Joint Pain

Rheumatic Fever

Angina (Chest Pain)

Cancer (Type)

Frequent Colds

Heart Murmurs

Constipation/ Incontinence

Pregnant

Palpitations

DVT/ Varicose Veins

Memory Loss

Dementia

Alzheimer

Circulatory Problem

Raynauds Syndrome

Depression

N / A

Required

Please give details:

Your answer

Are you on prescribed medication, herbs or supplements (including contraception)? *

Yes

(If yes, give details)

Your answer

Do you have any allergies / Allergic to Nuts? *

Yes

(If yes, give details)

Your answer

Do you have any contagious skin conditions/disease? *

Yes

(If yes, give details)

Your answer

Do you have any sensitivity on skin / skin disorder/ discomfort? *

Yes

(If yes, give details)

Your answer

Do / did you have any skin exfoliation? *

Yes

(If yes, give details)

Your answer

Have you ever had surgery? *

Yes

(If yes, give details)

Your answer

Have you ever had any broken bones? *

Yes

(If yes, give details)

Your answer

Do you suffer from back pain? *

Yes

(If yes, give details)

Your answer

Do you suffer from back pain? *

Yes

(If yes, give details)

Your answer

Do you have tension/soreness in a specific area? *

Yes

(If yes, give details)

Your answer

Do you have numbness/tingling/stabbing pain anywhere? *

Yes

(If yes, give details)

Your answer

Do you have any sensitivity on skin? *

Yes

(If yes, give details)

Your answer

Do you experience stiff, swollen or painful joints? *

Yes

(If yes, give details)

Your answer

Are these or any other injuries aggravated by exercise? *

Yes

(If yes, give details)

Your answer

Are these or any other injuries aggravated by exercise? *

Yes

(If yes, give details)

Your answer

Do any areas need to be avoided, due to discomfort it may cause you? *

Acne, Dermatitis, Hives, psoriasis, Moles, Burns, Ulcer, Open Wounds, Bruising, Varicose Veins, Fracture, Sprain, Bursitis, Muscular Haematoma, Other

Yes

(If yes, give details)

Your answer

Are special precautions required for your massage? *

Yes

(If yes, give details)

Your answer

Do you have difficulty lying on your front, back, side? *

Yes

(If yes, give details)

Your answer

Lifestyle Questions:

Your answer

Occupation: Please explain your position along with physical and mental responsibilities involved:

Your answer

Do you have an ergonomically set up desk/workstation?

Yes

Maybe

(If yes, give details)

Your answer

(If yes, give details)

Your answer

How many hours do you spend in front of a computer?

Your answer

How much time do you spend in a seated / standing position?

Your answer

How is your sleep pattern? & how many hours do you get?

Your answer

Do you follow, or have recently followed any specific dietary intake plan, and in general how do you feel about your nutritional habits?

Your answer

Do you smoke? (how many a day?)

Your answer

Do you drink? (units? (e.g. – 2 units in pint of beer and normal glass of wine (175ml)

Your answer

Treatment required today:

Your answer

Relaxation - Full body massage, Holistic Swedish Massage

Yes

(If yes, give details)

Your answer

Treatment - Back, Neck & Shoulders, Deep tissue, Myofascial Release

Yes

Therapy - Sport Massage, Remedial Therapy, Sleep Disorder

Yes

I understand that the massage treatment I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that pressure and/or strokes may be adjusted to my level of comfort. I affirm that I have stated all my known medical and non-medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical and non-medical profile and understand that there is no liability on the therapist’s part should I fail to do so. In the event that I become injured either directly or indirectly as a result, in whole or in part of the aforesaid massage therapist I HEREBY HOLD HARMLESS AND INDEMNIFY the therapist and her principals and agents from all claims and liability whatsoever; I hereby waive and release my Therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. (Please type your full Name) *

Your answer

Date: *

YYYY

Your answer

(Staff Only)

Your answer

Therapy Notes (Staff Only) Current Condition /Chief Complaint. When did the problem begin (Date)? What happened? Onset.

Your answer

Have you ever had this problem before? If yes what did you do for this problem?

Your answer

Have you ever had this problem before? If yes what did you do for this problem?

Your answer

Did you use Ice / Heat?

Your answer

Did that help?

Your answer

What describes the nature of pain? Sharp/ Dull ache/ Numb/ Shooting/ Burning/ Tingling (Check neurological signs) Pain Rating: 0 – 10 (10 being the worst)

Your answer

How often do you experience these symptoms? Constantly/ Frequently/ Occasionally/ Intermittently When is it worst? Morning, Evening, Sitting, Walking, Driving, Standing, other

Your answer

What activities make it worse? Cooking, Dressing, Using hands, Shopping, Dancing, Sport etc.

Your answer

What are your goals for therapy? – Reduce pain, improve flexibility, Walk unassisted, Increase stability, increase function, Increase strength, improve balance, improve posture, return to full activities, increase endurance.

Your answer

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