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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.
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Email
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Your email
You may be contacted regards your booking/s, Birthday, New Year, No more than 6 per year.
Appointment Date and Time:
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Your answer
Contact Information:
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Name:
Your answer
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Last Name:
Your answer
Mobile Number:
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Your answer
Date of Birth:
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MM
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DD
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YYYY
Postcode:
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Your answer
Occupation (Optional):
Your answer
Leisure pursuits:
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Your answer
How did you hear about N & N Joseph Massage Therapy?
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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)
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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 (Couple Massage is NOT suitable for pregnant ladies. (No Treatmnet will be provided))
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)?
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Yes
No
(If yes, give details)
Your answer
Do you have any allergies / Allergic to Nuts?
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Yes
No
(If yes, give details)
Your answer
Do you have any contagious skin conditions/disease?
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Yes
No
(If yes, give details)
Your answer
Do you have any sensitivity on skin / skin disorder/ discomfort?
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Yes
No
(If yes, give details)
Your answer
Do / did you have any skin exfoliation?
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Yes
No
(If yes, give details)
Your answer
Have you ever had surgery?
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Yes
No
(If yes, give details)
Your answer
Have you ever had any broken bones?
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Yes
No
(If yes, give details)
Your answer
Do you suffer from back pain?
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Yes
No
(If yes, give details)
Your answer
Do you suffer from back pain?
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Yes
No
(If yes, give details)
Your answer
Do you have tension/soreness in a specific area?
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Yes
No
(If yes, give details)
Your answer
Do you have numbness/tingling/stabbing pain anywhere?
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Yes
No
(If yes, give details)
Your answer
Do you have any sensitivity on skin?
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Yes
No
(If yes, give details)
Your answer
Do you experience stiff, swollen or painful joints?
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Yes
No
(If yes, give details)
Your answer
Are these or any other injuries aggravated by exercise?
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Yes
No
(If yes, give details)
Your answer
Are these or any other injuries aggravated by exercise?
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Yes
No
(If yes, give details)
Your answer
Do any areas need to be avoided, due to discomfort it may cause you?
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Acne, Dermatitis, Hives, psoriasis, Moles, Burns, Ulcer, Open Wounds, Bruising, Varicose Veins, Fracture, Sprain, Bursitis, Muscular Haematoma, Other
Yes
No
(If yes, give details)
Your answer
Are special precautions required for your massage?
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Yes
No
(If yes, give details)
Your answer
Do you have difficulty lying on your front, back, side?
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Yes
No
(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
No
Maybe
Clear selection
(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
No
Clear selection
(If yes, give details)
Your answer
Treatment - Back, Neck & Shoulders, Deep tissue, Myofascial Release
Yes
No
Clear selection
Therapy - Sport Massage, Remedial Therapy, Sleep Disorder
Yes
No
Clear selection
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)
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Your answer
Date:
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MM
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Your answer
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Your answer
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Your answer
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Your answer
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Your answer
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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
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Your answer
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Your answer
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Your answer
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Your answer
Have you ever had this problem before? If yes what did you do for this problem?
Your answer
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Your answer
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Your answer
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Your answer
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Your answer
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Your answer
Have you ever had this problem before? If yes what did you do for this problem?
Your answer
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Your answer
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Your answer
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Your answer
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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
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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
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Your answer
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Your answer
What activities make it worse? Cooking, Dressing, Using hands, Shopping, Dancing, Sport etc.
Your answer
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Your answer
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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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