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Massage Consultation -Form Fill

Section One
Q1

Full Name*

First Name
Q2

Full Name*

Middle Name
Q3

Full Name*

Last Name
Q4

Date*

Month
Q5

Date*

Day
Q6

Date*

Year
Q7

Address*

Street Address
Q8

Address*

Street Address Line 2
Q9

Address*

City
Q10

Address*

Borough
Q11

Address*

Postal / Zip Code
Q12

Address*

Country
Q13

Birth Date

Month
Q14

Birth Date

Day
Q15

Birth Date

Year
Q16

Phone Number*

Area code
Q17

Phone Number*

Phone Number
Q18

This is my:*
Q19

E-mail*
Q20

Emergency Contact Phone Number*

Area Code
Q21

Emergency Contact Phone Number*

Phone Number
Q22

Your Occupation
Q23

Do You Take Any Medication? *
Q24

Allergies*
Q25

1. List Areas of any Discomfort or Pain*
Q26

2. Describe Onset of Discomfort or Pain*
Q27

3. Level of Pain Today*
Q28

4. Frequency - please select the most accurate*
Q29

5. At what time of day is the pain at its worse?*
Q30

6. Have you ever injured this area before?*
Q31

7. Have you ever been in an accident (automobile, work, falls, etc.) ?*
Q32

8. If yes, list all related treatments received for the injury.
Q33

9. Have you ever received therapeutic massage for a specific problem or injury?
Q34

Was the treatment used effective?
Q35

10. Is there anything that you do that creates, increases or decreases pain? *
Q36

11. What are the physical duties required of your occupation?*
Q37

12. What activities/hobbies do you enjoy?*
Q38

13. How are your energy levels currently on a scale from 1 (low) to 10 (high)?*
Q39

14. How are your sleep patterns and how many hours do you sleep per night?*
Q40

15. Please list exercise and stress reduction / relaxation activities (including frequency).*
Q41

16. Do you take any of the following intoxicants?*
Q42

17. If you ticked any of the boxes above please state quantity and frequency of use*
Q43

18. In what position do you most often wake up?
Q44

19. Are you currently seeing any other healthcare professional? *
Q45

20. Please describe your typical daily diet and fluid (water, juice, herbal tea) intake*
Q46

Head
Q47

Neck
Q48

Shoulders
Q49

Arms & Hands
Q50

Mid-Back
Q51

Low Back
Q52

Hip
Q53

Legs and Feet
Q54

Circulation
Q55

Skin
Q56

Skeletal (bones)
Q57

Musclular
Q58

Neurological
Q59

Endocrine (Hormonal, glandular)
Q60

Respiratory
Q61

Digestion
Q62

Gynaecological
Q63

Signature*