Shop 3/ 1726 Gold Coast Hwy

Burleigh Heads. QLD. 4220.

Ph. 5535 5437

www.burleighheadsmassage.com.au

Patient Information

Date:
Title: Dr Prof Mr Mrs Ms Miss Master
Name:
Address:
Suburb:
Post Code:
Date of Birth:
Home Phone:
Mobile Phone:
Email:
Occupation:
Would you like to receive regular updates about your condition? Yes No

Patient History

Describe your pain:

Dull
Ache
Sharp
Stabbing
Pins & Needles
Shooting Pain
Burning
Throbbing
Twinge
Numbness/Tingling
Other


Is your pain constant? Yes No
Intermittent? Yes No

Fluctuates with activity? Yes No

Wakes you up at night? Yes No

What makes your symptoms worse?

Sitting
Standing
Walking
Lifting
Bending
Lying down
Squatting
Stress
Other

Type your pain or tightness place:


Are you ever totally pain free? Yes No

What makes your symptoms better?

Sitting
Standing
Walking
Lifting
Bending
Lying down
Other
What time of day are your symptoms worst? Best?
Do you feel you are: Getting better Getting worse Staying the same
Have you had this problem before? Yes No
If yes, when and how did it get better?
Any previous treatment for your current condition? Yes No
Have you had diagnostic studies for your current condition? (X-ray, MRI, CT scan...) Yes No
Any medical problems? Yes No     If yes, please explain:

Any surgeries? Yes No     If yes, please explain:

Please list ALL medications you are currently taking such as prescription and over-the-counter for this and any other condition:

What makes your symptoms better?

Major injury to head/spine
Cancer/tumors
Osteoporosis
Dizziness/blackouts
Heart problems/angina
Diabetes
Pacemaker
Sudden weight loss/gain
Severe pain at night
Smoking
Bruising easily
Asthma
Frequent falls
Loss of bowel/bladder control
Numbness
Seizures/Epilepsy
High blood pressure
Coordination loss


Please read and tick:

I understand that because our practitioners use their senses of touch and vision to assess, diagnose and treat patients, I may be asked to remove some items of clothing. I have been informed that if for any reason I feel uncomfortable with any aspect of the process of my assessment, examination or treatment, I may discuss this with my practitioner. I confirm also that I am aware that it is possible to have a chaperone in attendance.
I understand there are risks associated with Massage which may include
  • Muscle and Joint soreness
  • Increase in pain or severity of symptoms
  • Nausea, fatigue, diarrhoea
These side effects are rare and all steps are taken to ensure your safety. I do not expect the practitioner to be able to anticipate all potential risks and complications associated with the proposed care.
I also acknowledge that I have the opportunity to ask questions about the nature, extent and purpose of the proposed care at BHM and that I have been given sufficient time to make a decision regarding consent for the treatment to proceed.
I appreciate that results are not guaranteed.
I hereby acknowledge my consent to the performance of the proposed treatment at Burleigh Heads Massage for my presenting condition and for other future conditions(s) for which I seek treatment. I also understand that I can withdraw my consent for all or any aspect of treatment at any time through out the course of my treatment.
I agree that if I make an appointment and subsequently cancel it with less than 24 hours notice, I will be liable for a cancellation fee (a charge of $30 will apply for cancellation appointment). Please contact us as soon as possible if you need to cancel or reschedule an appointment so other patients requiring urgent treatment can be offered your appointment time.


Print Name:
Date:
Signature:

(Parent/Guardian of persons under 16 years of age)