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)