Verna-haywood Client Care Consultation Client Care Consultation Form Please enable JavaScript in your browser to complete this form.1Client Information2Health & Medical History3Pain and Discomfort4Lifestyle and Physical Activity5Goals and Preferences6General Health and Wellness7Feedback and Expectations8Consent and AgreementName *Email *Mobile No *Emergency Contact Name *Date of Birth *Gender *MaleFemaleOtherNextPrimary Health Concerns: *Are you currently receiving any medical treatment or therapy? *YesNoIf yes, please describe: *Do you have any chronic conditions or recent injuries? *YesNoIf yes, please describe: *List any surgeries or hospitalisations within the last 5 years: *Do you have any allergies (e.g., to oils, lotions)? *YesNoIf yes, please describe: *Are you pregnant or is there a chance you could be pregnant? *YesNoIf yes, please describe: (copy) *PreviousNextDo you have any specific areas of pain or discomfort? *YesNoIf yes, please describe the location, intensity (scale of 1-10), and nature of the pain (sharp, dull, throbbing, etc.): *Do you have any muscular or skeletal issues that are currently troubling you? *YesNoIf yes, please describe the location, intensity (scale of 1-10), and nature of the pain (sharp, dull, throbbing, etc.): (copy) *PreviousNextWhat is your typical level of physical activity? *Sedentary (little or no exercise)Lightly Active (light exercise/sports 1-3 days/week)Moderately Active (moderate exercise/sports 3-5 days/week)Very Active (hard exercise/sports 6-7 days a week)Extra Active (very hard exercise/sports and a physical job)Do you have a regular exercise routine? *YesNoIf yes, please describe the location, intensity (scale of 1-10), and nature of the pain (sharp, dull, throbbing, etc.): (copy) (copy) *Do you have any hobbies or activities that might affect your body (e.g., sports, manual labour)? *YesNoIf yes, please describe: *PreviousNextWhat are your primary goals for receiving massage therapy? (e.g., pain relief, stress reduction, improved flexibility, general relaxation) *Preferred Types of Massage: *SwedishDeep TissueSportsAromatherapyHot StoneOther (please specify):Preferred Pressure: *LightMediumFirmDeepAreas to Focus On: (e.g., back, neck, shoulders, legs, etc.) *Areas to Avoid: (e.g., sensitive areas, injuries, etc.) *PreviousNextDo you have any of the following conditions? (Check all that apply) *Heart diseaseHigh or low blood pressureOsteoporosisArthritisVaricose veinsSkin conditionsRespiratory issuesDigestive issuesOther (please specify):Do you take any medications or supplements regularly? *YesNoIf yes, please describe: *Do you have any concerns or conditions related to your skin (e.g., rashes, infections)? *YesNoIf yes, please describe: *PreviousNextHave you received massage therapy before? *YesNoWhat did you like or dislike about previous massage experiences? *Do you have any specific expectations or concerns regarding this therapy session? *PreviousNextI understand that the massage therapist is not a medical professional and that this therapy is not a substitute for medical treatment. *YesNoI consent to the use of my health information for the purpose of this therapy. *YesNoSubmit
