Client's Intake Form

About you

Full Name *

Email *

Phone No. *

Gender *

Street Address *

Suburb *

Post Code *

Age *

Reason for visit *

Referred by

Who is your Health Fund Provider? *

Pain & soreness

Please identify specific areas of soreness

Pain scale (10 being the strongest)

Frequency *

At what time of day is the pain at its worst? *

Have you ever injured this area before?

Have you ever been in an accident (automobile, work, falls, etc.)?

Have you ever received therapeutic massage for a specific problem or injury?

Medical history

Please list any recent or past injuries, illness and medical conditions

Are you currently on medication? *

Are you currently on other treatment? *

Terms & conditions

I have read and agree to the Terms & Conditions *

Signature *

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