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

Contact Information: *

Name:

*

Last Name:

Mobile Number: *

Date of Birth: *

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Can you be contacted regards your booking/s, Birthday, New Year? *

Postcode: *

Occupation (Optional):

Leisure pursuits: *

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

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

Medical History & Details:

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:

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

Yes

No

(If yes, give details)

Do you have any allergies / Allergic to Nuts? *

Yes

No

(If yes, give details)

Do you have any contagious skin conditions/disease? *

Yes

No

(If yes, give details)

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

Yes

No

(If yes, give details)

Do / did you have any skin exfoliation? *

Yes

No

(If yes, give details)

Have you ever had surgery? *

Yes

No

(If yes, give details)

Have you ever had any broken bones? *

Yes

No

(If yes, give details)

Do you suffer from back pain? *

Yes

No

(If yes, give details)

Do you suffer from back pain? *

Yes

No

(If yes, give details)

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

Yes

No

(If yes, give details)

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

Yes

No

(If yes, give details)

Do you have any sensitivity on skin? *

Yes

No

(If yes, give details)

Do you experience stiff, swollen or painful joints? *

Yes

No

(If yes, give details)

Are these or any other injuries aggravated by exercise? *

Yes

No

(If yes, give details)

Are these or any other injuries aggravated by exercise? *

Yes

No

(If yes, give details)

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

No

(If yes, give details)

Are special precautions required for your massage? *

Yes

No

(If yes, give details)

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

Yes

No

(If yes, give details)

Lifestyle Questions:

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

Do you have an ergonomically set up desk/workstation?

Yes

No

Maybe

Clear selection

(If yes, give details)

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

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

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

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

Do you smoke? (how many a day?)

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

Treatment required today:

Relaxation - Full body massage, Holistic Swedish Massage

Yes

No

Clear selection

(If yes, give details)

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) *

Date: *

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(Staff Only)

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

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

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

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Did you use Ice / Heat?

Did that help?

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

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

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

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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.

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