Myotherapy / Remedial Massage Intake Forms

Full Name:*

Mobile:*

D.O.B*

Email:*

example@example.com

Home Address (Including Suburb):*

How did you hear about us?

Medical/Trauma history:

Do you exercise at least weekly?

YesNo

What exercise/activities do you undertake?

Reason for consultation:

Affected areas:

Previous treatment:

Medications:

I hereby consent to a myotherapy or remedial massage treatment inluding but not limited to dry needling, moxibustion and vacuum cupping. These treatments may lead to tenderness and bruising. I will ask my practitioner for further details about these if required.

I understand and accept the use Body In Balance Chiropractic have with holding information present on my file.

Signed*

Preferred level of conversation during massage sessions?

NoneInstructional/ExplanationMedium Conversation

Date:*