Client health assessment form

Deep Impact Massage > Client health assessment form

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

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    Contact Details:
    Date of treatment

    Your name

    Your address

    Your email

    Your contact mobile

    Your profession

    How did you hear about me?

    Health History - Medical Details
    Please list any medical conditions you have (leave blank if not applicable)

    Are you currently seeing a doctor, physiotherapist, chiropractor or osteopath?

    What medication (if any) are you regularly taking? (leave blank if not applicable)

    Have you broken any bones or had an operation/major accident in the last 6 months?

    Health History - General Details
    Please describe your general health over the last month i.e. colds, energy levels, normal routine

    Please describe your daily sleeping, eating and drinking routines

    Please select your stress levels at home (0 = lowest, 10 = highest)

    Please select your stress levels at work (0 = lowest, 10 = highest)

    How do you cope with stress?

    Health History - Average Week
    Please describe your average working week (leave blank if not applicable)

    Please describe your average exercise routine during the week (leave blank if not applicable)

    Do you have or look after any children? How does this affect your week? (leave blank if not applicable)

    Do you have any down time or relaxation during the week? (leave blank if not applicable)

    Would you define your average week as busy, middling or relaxed?

    Health History - Reason for treatment
    Please tell me why you are coming for treatment?

    Health History - Pain Assessment
    Do you have pain?

    Are you currently in pain?

    When did it start? (a general time period for how long you've experienced the pain)

    What do you think is the originating source of this pain?

    What makes the pain better?

    What makes the pain worse?

    What type of pain do you have? (e.g. dull, acute, sharp, nagging, throbbing, intermittent, electrical, nervy, muscular, fatigue, sensitivity)

    Does your pain radiate or is it local?

    Where exactly is your pain? (be as specific as you can, please list all areas)

    Please prove you are human by selecting the House.