Please complete the following health assessment form before attending your session with Deep Impact Massage, alternatively you can download a paper copy here.

All information you enter here is securely transmitted and encrypted.

Your treatment details

Date of your treatment (format YYYY-MM-DD)

Time of your treatment

Your contact information

Your Name (required)

Your address (required)

Your Email (required)

Contact telephone/mobile (required)

Your profession (required)

How did you hear about me? (required)

Health History - Medical Details
(please complete as fully as you can)

Detail any relevant medical conditions

Are you current seeing a doctor, physiotherapist, chiropractor or osteopath?
YesNo

Detail any relevant medication that you are currently prescribed and taking

Have you had any recent broken bones, operations or major accidents?
YesNo

Health History - General Health Details
(please complete as fully as you can)

Detail briefly your health over the last month

Detail briefly your sleeping, eating and drinking routine over the last month

Detail briefly your stress levels at home and work, and how you cope with stress

Health History - Describe an average week
(please complete as fully as you can)

Briefly describe a typical working week

Briefly describe what physical exercises you undertake each week

Briefly describe your family commitments and children, if any

Briefly describe what you do for downtime and relaxation

Would you describe a typical week as generally busy or relaxed
BusyRelaxed

Why are you coming for a treatment?

Health History - Pain Assessment
(please complete as fully as you can)

Do you have pain?
YesNo

Are you currently in pain?
YesNo

The Origin of your pain

When did your pain start? (a week ago, a month ago, a year ago - be as specific as you can)

What do you think is the originating cause of your pain?

Provoking factors of your pain

What makes your pain better?

What makes your pain worse?

The quality of your pain

Can you describe what type of pain you have? (nervy, dull, sharp, deep, shallow, muscular, joint) - be as descriptive as you can

The nature of your pain

Is your pain local to an area, or does it refer anywhere else?
LocalRefers

The site of your pain

Where exactly is your pain? Describe exactly where your pain is

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