Health evaluation Learn more If you are a human and are seeing this field, please leave it blank. First name Last name Address City/Suburb State New South Wales Victoria Queensland Western Australia South Australia Tasmania Australian Capital Territory Northern Territory Postcode Date of birth Occupation Email Phone In case of emergency Emergency Contact Name Emergency Contact's Number Medical Contact Name Medical Contact's Number — General Health Evaluation Reason for treatment? Frequency of physical activity? None 1-2 times a week 3-4 times a week More than 4 times a week Type of physical activity? Intensity of physical activity? Mild Moderate Intense Competition How would you describe your stress levels? How would you describe your energy levels? Do you smoke? YesNo Do you have any history of hypercoagulable state, clot, emboli or thrombi? YesNo List any allergies or sensitivities with foods, oils, and essential oils Do you have any metal implants, a pacemaker or body piercings? Have you ever undergone any major surgery? YesNo Have you had any health conditions, past or present, that may interfere with the treatment? E.g. Migraine, allergies, joints dislocation history, any kind of injury. What other types of treatments are you currently having? PhysiotherapyChiropracticeNaturopathyAcupuncture Please select if you've had any of the following Acute joint pain/injuryAsthmaArthritisBroken bonesDizziness or faintingDepressionHeart diseaseEpilepsyHerniaStomach / Duodenal ulcerGlandular feverNumbnessPalpitations or chest painsHeart condition / murmurCancerGoutH.I.V / AIDSChronic painInfectious conditionsHigh blood pressure (130/90 +)MenopausePost partumLiver or kidney conditionNeck or spine injuryDiabetesLow blood pressure (normal=120/80)Loss of balanceBlood clots or DVTRaised cholesterol / triglyceridesJoint replacementsRheumatic feverInsomniaOsteoporosisStroke individuality I wear contact lensesI chill easilyI overheat easilyI don’t mind the appropriate use of vegetable and essential oils on my face and hair How you prefer your massage Pressure 1=Gentle, 5=Very firm 1=Even pressure, 5=Pressure point 1=Soothing & restful, 5=Physically energised & refreshed For Women Are you pregnant? Yes No Are you breast feeding? Yes No Date of last period I have read & consent to the massage therapy treatment Full details below CONSENT TO MASSAGE THERAPY TREATMENT I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by the Association of Massage Therapists Ltd (AMT). I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended, by my therapist. I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I have read the above noted consent and I understand that I will have the opportunity to question the contents and my therapy. By submitting this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
