Massage client history form

First Name *

Last Name *

Preferred pronouns (if desired)

Please specify your preferred pronoun(s)

Preferred name (if desired)

Date of birth *

Street address *

Suburb *

Phone *

Email Address *

Occupation

Name of private health fund (if applicable)

What do you want to get out of your massage? (Select all that apply.) *

Relaxation/relief from stressRelief from physical painPreparation for sport/physical activityRecovery from sport/physical activityGeneral health maintenanceI just enjoy getting a massage!

Please note that private health insurance claims are only available for remedial massage treatments, which address pain and dysfunction in muscles, tendons, ligaments and connective tissue. If you wish to be able to claim on private health, you will need to select 'Relief from physical pain' above and describe your symptoms.

What pain(s) are you experiencing that you'd like to address? Where is the pain? Is it sharp or dull? Does it radiate or refer anywhere? Roughly how long have you had the pain? Was there something in particular that you think caused the pain? Does it stop you from doing anything?Don't feel you have to answer every question. Feel free to include as much or as little detail as you like.

What is the other diagnosed medical condition?

Are you currently taking any medications or receiving any ongoing medical treatment (e.g. cancer treatment)? *

YesNo

Which medications and/or treatments are you currently taking/receiving?

Do you have any allergies? *

YesNo

What are they?

General state of health

Please indicate how you consider yourself in each of these areas of general health. Select one option for each area.

Fitness

Physical strength

Wellness

Stress

Diet

Exercise

Sleep

Which other area would you prefer NOT to be massaged?

Do you give permission for the therapist to include the upper buttocks in the massage? *

YesNo

The muscles in this area are often involved in lower back pain. Not being able to access the upper buttocks will limit the therapists' ability to treat lower back pain.

What is your preference for the massage?

I like a bit of a chatI prefer not to talkI don't mind

Where did you hear about Time & Space Therapies?

Who was this lovely person?If it's someone I know, I'd like to be able to thank them for referring you.

Do you recall where? No problem if not.

Would you like me to add your email address to my mailing list?

Yes pleaseNo thanks

I don't send out newsletters very often, but occasionally I'll pass on special offers, news or helpful information.

Cold and flu policy

It is your responsibility to notify the Massage Therapist at the time of booking if you have an illness such as a cold, fever or flu. You may be advised not to attend, as massage can exacerbate the symptoms and leave you feeling worse. If you arrive for a massage obviously suffering from a cold or flu, your Therapist reserves the right not to treat you and may request 50% of the fee that would have been paid for the session.

Cancellation policy

It’s totally fine if you need to cancel or reschedule an appointment, but please try to give as much notice as possible. Cancellations made with fewer than three hours’ notice may, at the Massage Therapist’s discretion, attract a penalty of 50% of the fee that would have been paid for the session. This is payable at the subsequent session. Non-attendance without notice may, at the Massage Therapist’s discretion, attract a penalty fee of 75% of the fee that would have been paid for the session. This will be automatically deducted from your stored credit card.

Client declaration

I declare that all the answers and statements contained in this personal record, are true and complete. Because a Massage Therapist must be aware of all past and present physical conditions, I have stated all my known medical conditions and take it upon myself to keep the Massage Therapist updated on my physical health during any treatments. I understand that all information I have provided on this form is held by the therapist in the strictest confidence.

Signature *

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