Working Hands Massage Therapy Questionnaire

Your Details

Title—Please choose an option—MrMrsMissMsDrRevOther
Name
Address and Postcode
Email [/uacf7-col][uacf7-col col:6] Contact Number
Name & Address of GP
How did you hear about me?—Please choose an option—RecommendationWebsiteSocial MediaGoogle SearchOther

Medical History

Do you suffer or ever suffered of any of the following?

Thyriod—Please choose an option—YesNoStroke—Please choose an option—YesNoHeart Conditions—Please choose an option—YesNo

Thrombosis/phlebitis—Please choose an option—YesNo
Rheumatoid Arthritis—Please choose an option—YesNo
Cancer—Please choose an option—YesNo

Epilepsy—Please choose an option—YesNoRecent surgery—Please choose an option—YesNoAsthma or other Respiratory Conditions—Please choose an option—YesNo

Digestive Problems—Please choose an option—YesNo
Diabetes—Please choose an option—YesNo
Headaches—Please choose an option—YesNo

Steroid Use—Please choose an option—YesNo
Allergy—Please choose an option—YesNo
Blood Pressure Issues—Please choose an option—YesNo

Anxiety—Please choose an option—YesNo
Skin Infections/Conditions—Please choose an option—YesNo
Depression—Please choose an option—YesNo

Are you going through menopause?—Please choose an option—YesNo
Are you pregnant? If so, how many weeks—Please choose an option—No12345678910111213141516171819202122232425262728293031323334353637383940
Please give details of any of the above including regular medication you are taking

Your Health and Wellbeing

Is there anything else about your health and wellbeing you would like to tell us?

Where are you at the moment in the pain scale below?

When Did it Start?

When did you first notice the pain?

What makes it worse?
What makes it better?

Lifestyle Questions

These questions help us to understand the close rapport between your lifestyle and the current issue

What physical activity / sports do you do during the week? And how often

What's your mood recently?

What’s your general feeling of Stress recently?

Sleep

How do you rate your quality of sleep?
[uacf7_range_slider uacf7_range_slider-sleep min:1 max:10 default:5 show_value:on "default"] How many hours sleep do you usually get?—Please choose an option—1234567899+

Hobbies

Hobbies, what do you like to do?
What brings you to see me, what are your reasons for treatment, what results do you expect?

Declaration and Informed Consent

The information I have given in this form is honest, accurate and correct to the best of my knowledge. I have been given the opportunity to ask all the questions about its content, and all of my questions have been answered to my satisfaction. I appreciate that although all reasonable steps to reduce risk of infections have been taken, including screening potential Covid-19 cases and undertaking increased hygiene and distancing protocols there may still be a risk of infection from face to face appointment. I knowingly and willing consent for Face to Face appointment to take place.

Date
Signature[uacf7_signature uacf7_signature-69]

"The Clinic fully complies with the most up to date Data Protection Policy and has a transparent approach to Data Processing which empowers individuals to know about the collection and use of their personal data. We collect data for ensuring we have the right information for assessing your suitability to treatment, for completing the appropriate treatment, for contacting you regarding appointment follow-ups and for a referral to GP or other healthcare practitioners if deemed necessary. Your data may be viewed by clinic staff to ensure continuity of care is given and for standards clinic running purposes. In addition, the data will also be shared with NHS Trace and Test if asked as this is mandatory. The Therapist has the right to refuse treatment if such data cannot be collected. We collect only data that is relevant to those purposes, and we keep it for 7 years. All information held will be treated as strictly confidential and will only be released to any other external party with the consent of the client."
I have read The Clinic’s Data Protection Policy and consent to The Clinic processing records as outlined above and understand that I can withdraw my consent on the processing of data at any time.

Treatment consent

You will complete this AT THE TIME OF YOUR APPOINTMENT
The information I have given in this form is correct to the best of my knowledge I have been explained the effects, benefits and risks associated with treatment including Covid-19 risk of infection. I have had the opportunity to ask all the questions about the process, and all of my questions have been answered to my satisfaction. I consent for treatment to take place and understand that I can withdraw my consent at any time.

By clicking this button you are agreeing to our Terms and Conditions & Data Protection Policy.

Please Upload Your Pain Document