My Bodyworks New Client Intake Form

Thank you for taking the time to fill out this health questionnaire. Please complete and return the form to me at least 48 hours before your appointment to allow me sufficient time to prepare for your visit.

All information is strictly confidential and will never be shared or disclosed with third parties. Information will not be shared with referral to another medical professional without your prior written consent.

All history is totally relevant to how your body responds to everyday activities and injuries so please try to fill in as much information as possible. Often incidents which you feel are nothing could in fact be everything - a drunken fall as a teenager, a small scar, a slight ankle sprain.

You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

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About your session

Your session may contain elements of movement as well as massage and release work. With this in mind, please make sure you are wearing clothes that you can move in.
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

Town County

Postcode
E-mail *
Phone Number *
Mobile Number *
Emergency Contact *
Emergency Contact Phone Number *
Occupation *
Hobbies *
Allergies *
Medications *
PRESENTING COMPLAINT
1. What’s your ‘Primary Complaint’? (The most significant ache, pain or niggle that you’d like us to look at and help you with during your session visit?) PLEASE INCLUDE SIDE OF PAIN, WHAT MOVEMENTS EXACERBATE THE PAIN, WHEN AND HOW LONG YOU EXPERIENCE THE PAIN *
2. Past Injury History. Any physical injuries, traumas or accidents to the following (this includes broken bones, strained muscles, ankle sprains, falls onto the tailbone, bangs to the head, concussion, whiplash, scars) - please tick *

Feet Ankles Lower legs Knee Upper leg / groin Pelvis Abdominal organs Lower back, sacrum , coccyx Mid back, ribs Shoulders Elbows Wrists Neck Head Eyes Teeth
If you have ticked any of the above, please give details and dates below *
3. Any previous Dental Work, Eye work, Medical Investigations, Treatments or Surgeries? *
4. Piercings and Tattoos *
5. On a scale of 1-10, how full is your 'stress bucket'? *
6. Are you currently seeing any other healthcare professional? *
GENERAL MEDICAL HISTORY

Do you suffer, or have you suffered from any of the following conditions:
*

CIRCULATION PROBLEMS (Heart disease, pulmonary odeama, high/low blood pressure, poor circulation, DVT, Varicose Veins) RESPIRATORY SYSTEM (Asthma, bronchitis, hay fever) SKIN DISORDERS (Cellulitis, Dermatitis, eczema, psoriasis, sensitivity, fungal infections) MUSCULAR OR SKELETAL PROBLEMS (Fibromyalgia, previous fractures, Arthritis) NEUROLOGICAL PROBLEMS (Sciatica, epilepsy, migraine, dizziness, fainting) URINARY PROBLEMS (Cystitis, thrush, kidney problems) IMMUNE SYSTEM (Prone to colds, reduced immune status) GYNAECOLOGICAL PROBLEMS (PMT, menopause, HRT, irregular periods) HORMONAL PROBLEMS (Diabetes, Hypoglycaemia) DIGESTIVE PROBLEMS (Indigestion, constipation, IBS, Crohns) STRESS RELATED OR PSYCHOLOGICAL PROBLEMS (Depression, mood swings, anxiety, panic attacks) CANCER NONE OF THE ABOVE
If you have ticked any of the above, please add more detail with dates in this box
PREGNANCY AND POST NATAL HEALTH
How many pregnancies have you had?
Natural or assisted (c-section, forceps, ventuse, episiotomy) delivery?
Have you had any miscarriages or terminations?
Do you suffer, or have you suffered from any of the following conditions as a result of pregnancy and / or birthing:

Diastasis Recti C-section scar Prolaspe (uterine, Bladder, Rectal, Vaginal) Sacrum or Sacroiliac Joint Pain (pain in very low back/top of buttocks) Lack of bladder/bowel control Carpel Tunnel Syndrome Coccyx Damage or Pain Epidural given during birthing Buttock/ Piriformis Pain Breast Feeding Episiotomy Cut or tear during birthing
NEWSLETTER CONTACT CONSENT
We would love to send you newsletters and useful info from My Bodyworks by email. We'll always treat your personal details with the utmost care and will never share, disclose or sell them to any third parties. You can read more about our privacy policy at http://www.mybodyworks.uk/ Please let us know if you would like us to contact you or not by selecting one of the options below *

Yes please, I'd like to hear your news and tips. No thanks, I don't want to hear your news and tips.
Signature *

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Date *

Day Month Year
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