First Name*Surname*DOB*AddressSuburbPostcodeMobile*WorkEmail*Marital StatusSingleMarriedDe factoWidowDivorcedOccupationSexMaleFemaleHow did you hear about us?Walked pastGoogleVoucherYellow PagesWord of MouthOtherIf Word of Mouth or Other, please indicate who or where. If you found us through Google, please indicate the keywords you typed in the search box. e.g. Massage north sydneyGP or Medical Practice detialsGP or Medical Practice detailsGeneral HealthHave you had massage before?YesNoHow Often?How firm do you like your massage?SoftFirmHardDetailsAccidentsYesNoDetailsPrevious surgery (incl. Breast Augmentation)YesNoDetailsAre You Pregnant?YesNoDue Date? How many weeks?Current Medications?YesNoConditions?Current Vitamins / SupplementsYesNoDetailsLifestyle and WellnessExerciseNoneIrregularRegularlyDetailsSportsSocialCompetitiveDetailsDietPoorFairGoodExcellentDetialsSleepPoorFairGoodExcellentHow many hours per night?StressLowMediumHighlyDetails Work / Home etc?SmokingYesNoCigarettesAlcoholYesNoDrinks per week?Please select if you currently have or previously had any of these conditions in the past. SKINInfectionsRashesPsoriasisHEAD/NECKHeadachesMigrainesWhiplashNERVE INVOLVMENTNumbnessPinched NervePins & needlesHerniated diskCarpal TunnelSciaticaCARDIVASCUARHeart disease/strokeHigh BP/ Low BPRheumatic feverAnginaPacemakerBleeding disorderVaricose veinsBlood clots/DVMUSCULOSKELETALOsteoarthritisOsteoporosisRheumatoidTendonitisFibromyalgiaFracturesOthersMultiple SclerosisAllergiesDiabetesEpilepsyParkinson's diseaseAsthmaAny other Health Related issues? i.e.heart problems, diabetes, hypertension, cancer, depression and anxiety, asthma, arthritis and/or osteoporosis?If you could improve anything about your health, what would be your goals?1:2:3:Please select the area of pain and indicate on a score of 0 to 10, how intense the pain is. (0=no pain, 10=extreme pain)Area of pain?Pain Rating12345678910Are there any other symptoms associated with this problem?Terms & Conditions I understand that there are possible significant risks and complications specific to my individual circumstances that may have a bearing upon my decision to proceed with the proposed treatment. The therapist has explained the treatment options to me and will discuss with me during the treatment if she/he makes any further changes to the treatment. The therapist has explained the associated risk and possible side effects with this treatment and any potential risks or outcomes if the treatment is changed. The therapist has explained that I have the right to refuse treatment or changes to the treatment and that she/he or I have the right to stop the massage at any time. I understand that I have the right to ask for further information on treatments that include breast, buttock or groin areas and refuse treatment of these areas at any time. I give consent to my patient notes to be shared with practitioners/therapists that work within North Sydney Sports and Chiropractic and will not be used for any other purposes than the treatment of my condition and health.. *I hereby acknowledge that I have read the above. I hereby give consent to the proposed treatment outlined by my practitioner.