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Home
About
Treatments
Remedial Massage
Cupping Therapy
Myofascial Dry Needling
Manual Lymphatic Drainage
Relaxation Massage
Deep Tissue Massage
Sports Massage
Hot Stone Massage
Pricing
Book Now
Contact
Health History Form
Please ensure you fill out this Health History Form no less than 24 hours prior to your appointment. To save time on the day of your appointment, this information will be transferred onto our system and confirmed by you in person. By fill out this form, you consent to our terms and conditions.
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
Phone
*
Date Of Birth
*
Address
*
If you have booked a mobile treatment, please enter the address your treatment is to be conducted at.
Occupation
*
Date and Time Of Booking
*
Treatment Location
*
--- Select Choice ---
In Clinic Treatment
Mobile Treatment
Pregnant? you Name
What type of Treatment did you book?
*
--- Select Choice(s) ---
Remedial Treatment
Manual Lymphatic Drainage
Myofascial Dry Needling
Relaxation Massage
Pregnancy Massage
Deep Tissue Massage
Cupping Therapy
Hot Stone Massage
Sports Massage
Select all that apply.
Current Medications
*
Please list all current medications you're taking including over the counter medication. Please include dosages as required. If you aren't taking any medications simply write N/A.
Are you currently Pregnant?
*
If Yes, please state how far into your pregnancy you are.
Why are you getting Treatment?
*
Please list any applicable pain and symptoms you may be experiencing.
Please indicate any of the following that apply to you
Inflammation
Fluid Build Up (Oedema)
Allergies/Sensitivities
Recent Surgery
Headaches/Migraines
Varicose Veins
Numbness
Nerve Pain
Diabetes
Stroke
Blood Clots
Arthritis
High/Low Blood Pressure
Sprains or Strains
Kidney Dysfunction
Joint Replacement(s)
Heart Attack
Cancer
NONE OF THE ABOVE
Conditions are relevant to the current time and past history.
Explain any conditions you have marked above including dates and duration if applicable.
Have you had a professional massage before?
*
--- Select Choice ---
Yes
No
What are your goals for this treatment session?
*
Signature
*
By signing above, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. By signing above, you agree to recognise this form as a replacement of signing a paper copy medical history form. I have read, understood and agree to the terms and conditions listed on liability release forms and terms and conditions provided by AMD Massage Therapies.
Submit
