Date Of Birth (use the calendar or type yyyy/mm/dd
What Exercise do you currently do?
Current Exercise Frequency
Rarely (once per month)
Sometimes (once per week)
Regularly (2 or 3 times per week)
Often (4 or more times per week)
How did you hear about us?
Private Health Insurer
Is Massage Covered by your Private Health?
Is Naturopathy Covered by your Private Health?
Doctor Or Other Care Giver Name
Doctor Or Other Care Giver Phone
How Often Do You Get a Massage?
This is the first time
Rarely (around once per year)
Sometimes (2 - 4 times per year)
Regularly (4-11 times per year)
Often (12 or more times per year)
Please Mark If You Have Any Of The Following
High/Low Blood Pressure
Thrombosis (blood clots)
Illness, accidents or surgery in the last 5 years
Allergy to Oils, Smells, Lotions
Pain while lying prone or supine (face down or face up)
Are you Pregnant or Breastfeeding
Yes, Breast Feeding
(if pregnant) How Many Weeks Pregnant
(if pregnant) what is your due date?
(if pregnant) Medical Caregivers
Where do you feel pain or discomfort?
What makes the pain better?
What makes the pain worse?
List Current Medications & Supplements
I declare this is true and correct