Client Record Form

CLIENT DETAILS

 

Mr / Mrs / Miss / Mrs (required)

First Name (required)

Surname (required)

Date of birth - dd/mm/yyyy (required)

Contact Number (required)

Email Address (required)

Home Address (required)

Address for massage treatment (required)

Male / Female / Other (required)

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GP DETAILS

 

Name (required)

Contact number (required)

Surgery address (required)

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EMERGENCY DETAILS

 

Name (required)

Relationship (required)

Contact Number (required)

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MEDICAL HISTORY

 

Do you have, or have you had in the past 6 months, any of the following symptoms/conditions?
 

OBSERVABLE CONTRAINDICATIONS:
Skin disorders (Eczema)FeverRecent OperationsInflammationSprains and StrainsCutsBruisesBurnsFracturesInfection (Septicaemia)BursitisVaricose VeinsSwelling (required)

 

GP CONTRAINDICATIONS:
CancerCardiovascular Disease (Heart)Undiagnosed LumpsEpilepsyNervous System DisordersLymphatic System DisordersAutoimmune Disorders (HIV and AIDS)High/Low Blood PressurePneumoniaThrombosis (DVT) (required)

 

PERCAUTIONARY CONDITIONS:
Medically Weak SkinBone, TissuesHaemophiliaPregnancyUndiagnosed Musculoskeletal Disorders / Asthma / AllergiesHeadachesSinusitisDiabetesSubstance Addiction

 

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ANY OTHER CONDITIONS:

 

Additional Details: If you answered YES to any of the previous questions, please provide further details below.

 

If required, has permission been given by the GP/Consultant to carry out the treatment (please bring the letter to your first treatment) NoYesNot Required

 

Have you visited your GP in the last 6 months? (required) NoYes

Are you on any prescribed medication? (required) NoYes

Are you receiving treatment from another healthcare professional? (required) NoYes

 

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CONSENT

 

I hereby confirm that the information stated above is accurate to the best of my ability. I further fully understand that thorough and honest responses to these questions are essential to my safety. I undertake to inform my therapist of any changes to the above information (required). I AGREE

 

I understand that an assessment needs to take place in order to establish a treatment plan. All assessment and treatment procedures have been thoroughly explained and I am happy to proceed (required). I AGREE

 

Date - dd/mm/yyyy (required)

 

Client Signature (required):