top of page
CART
Log In
First name
Last name
Email
Phone
Birthday
Month
Day
Year
Email
Phone
Occupation
How did you hear about us?
What activities (exercise/ Sport hobbies) do you take part in?
Health Fund
Previous Treatment
CLIENT HISTORY Please tick all conditions that apply (please include past conditions)
Abdominal or Digestive Problems
Allergies
Arthritis
Asthma or Lung Conditions
Bladder or Pelvic Health Conditions
Blood Clots
Cancer / Tumors
Chronic Fatigue
Chronic Pain (> 6months)
Depression
Diabetes
Dizziness
Epilepsy
Fibromyalgia
Gout
Headaches or Migraines
Hearing Problems
Heart or Circulatory Problems
Hernias
High or Low Blood Pressure
Hypermobility / Ehlers Danlos Syndrome (EDS)
Infectious Disease
Insomnia or Sleep Difficulties
Lymph Node Removal
Lymphedema
Loss of Balance
Motor Vehicle Incident / Trauma
Muscle or Joint Pain
Muscle / Bone Injuries
Night Pain
Numbness or Tingling
Overuse Injury
Phlebitis (superficial blood clot)
Pregnancy
Rash / Athletes Foot / Tinea
Raynaud's (poor circulation in hands and feet)
Scars (Major)
Skin Disorders
Spinal Injuries
Stress/ Anxiety
Stroke
Surgeries/ Joint Replacements
Varicose Veins
Vision Problems / Contact Lenses
Expand on the areas ticked above:
Any other conditions not listed?
If pain is chronic (> 6 months); how long have you had it?
Current Medications: including aspirin, ibuprofen, vitamins, homeopathic and naturopathic remedies etc:
Presenting condition: how it happened and the areas affected.
What are you after by your therapist today?
Signature
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Submit
bottom of page
