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 NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

Postcode
E-mail*
Phone Number*
Mobile Number*
Date of Birth*

DayMonthYear
Date
Occupation*
Hobbies*
Allergies*
Medications*
Emergency Contact & Phone Number*
Doctor Name & Surgery
PRESENTING COMPLAINT
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*
What are your goals for treatment?*
Are you currently seeking help from any other health professional? GP, Orthopedic, Osteopath, Chiropractor, Physiotherapist, Massage Therapist, Nutritionist, Other?*
GENERAL MEDICAL HISTORY

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

FracturesStrainsSprainsJoint replacementArthritisOsteoarthritisOsteoporosisBursitisTendonitisBack ConditionJaw PainSpinal Issues/ Disc IssuesFibromyalgiaMetal Pins or PlatesOtherNOT APPLICABLE
CIRCULATORY ISSUES*

Heart ConditionsHypertensionHypotensionDVT/ Blood ClotsVaricose VeinsEmbolismThrombosisLymphedemaCV DiseaseHaemophiliaPhlebitisPace MakerOther Medical ImplantOtherNOT APPLICABLE
STRESS REALTED OR PSYCHOLOGICAL ISSUES*

DepressionAnxietyPanic AttacksSchizophreniaStressOtherNOT APPLICABLE
RESPIRATORY ISSUES*

COVID -19AsthmaHay FeverPneumoniaBronchitisEmphysemaSinusitisRhinitisColdCoughFluOtherNOT APPLICABLE
SKIN ISSUES*

PsoriasisEczemaAcneHerpesImpetigoCellulitisUndiagnosed LumpsRashesOpen WoundsBurnsFungal InfectionsWartsDermatitisLypomasOtherNOT APPLICABLE
DIGESTIVE ISSUES*

IBSCrohnsColitisConstipationDiarrhoeaGall StonesKidney StonesUlcersAcid refluxIndigestionOtherNOT APPLICABLE
NEUROLOGICAL ISSUES*

SciaticaEpilepsyMigrainesDizzinessFaintingNumbness/ TinglingPinched NerveParalysisNeuralgiaMultiple SclerosisParkinsonsTinnitusOtherNOT APPLICABLE
EYE ISSUES*

SurgeryLaser correctionGlassesContact LensesLazy EyeEye StrainOtherNOT APPLICABLE
JAW & THROAT ISSUES*

TMJTeeth GrindingClenchingBracesDifficulty swallowingRoot CanalBridgeFalse ToothWisdom teeth extractionTonsillectomyAdenoid removalOtherNOT APPLICABLE
URINARY ISSUES*

CystitisThrushKidney IssuesOtherNOT APPLICABLE
HORMONAL ISSUES*

DiabetesPMTHRTMenopauseIrregular PeriodsTampon UsageIUD usageOtherNOT APPLICABLE
IMMUNE SYSTEM ISSUES*

CancerRheumatoid ArthritisAidsHIVLymph Node removalOtherNOT APPLICABLE
MISCELLANEOUS*

Have you ever had a general anesthetic?Have you ever had anything down your throat (camera/sword/ etc)?Do you wear a fit bit or smart watch?NOT APPLICABLE
Are you wearing or do you normally wear:*

Hearing AidDenturesContact LensesWigMedical ImplantProstheticOtherNOT APPLICABLE
PAST INJURY HISTORY
Please list any physical injuries, surgeries, traumas or accidents you may have had, even if they seem unrelated to your current complaint. Include a rough idea of dates. (This includes and is not limited to: broken bones, strained muscles, sprains, falls onto the tailbone, bangs to the head, concussion, whiplash, medical investigations, scars, feet, hands, ribs, pelvis, organ issues, teeth, eyes) *
Piercings and Tattoos*
On a scale of 1-10, how full is your 'stress bucket'?*
BREATHING SECTION
Please tick any of the symptoms that relate to you:*

NOT APPLICABLECoughingWheezingExercise Induced asthmaFrequent coldsBreathlessness at restFrequent sighing/yawningSleep ApnoeaSnoringSlow back painHigh perceived stressExcessive sweatingTummy upset/IBSAchy MiusclesTirednessInsomnia/ broken SleepPoor concentrationPanic attacksHeadachesInability to breathe deeplyUpper chest breathingAnxietyBlurred VisionNasal IssuesFeeling tenseDizzy SpellsChest tightness
PREGNANCY AND POST NATAL HEALTH
Please tick any of the conditions below, applicable to your pregnancy , birth or post natal period*

NOT APPLICABLECaesarean sectionEpisiotomyTearEpiduralAssisted Forecps deliveryAssisted Ventuse deliveryDiastasis (separation of the abdominal wall)Uterine prolapseBladder prolapseVaginal ProlapseRectal ProlapseSymphysis pubis dysfunction (SPD)Sacrum or SIJ painCarpal tunnel syndromeUpper back, neck , shoulder painCoccyx damage or painIncontinence (Urine or fecal(Piles/Haemorrhoids/ Varicose veins/ constipationGestational diabetesC section wound healing discomfort or ongoing numbnessJoint/ Muscle PainButtock or piriformis painSciaticaLow Back PainVreats Health / Breast Feeding IssuesHistory of thrombosis or cllotsEpisodes of feeling faint/ dizzyHigh/ Low blood pressurePre eclampsia(Pudendal) Nerve Damage during birthAnaemia or iron medicationTerminationMiscarriage
How many pregnancies have you had?*
HYSTERECTOMY SECTION
Hysterectomy Surgery type*

NOT APPLICABLEPartial (Upper uterus removal)Full (Uterus and cervix removal)Hysterectomy with Bilateral Salpingo-oopherectomy ( Uterus+cervix+fallopian tubes + ovaries)Radical (Uterus + cervix + ovaries + fallopian tubes + upper vagina + lymph node removal)
Surgical Procedure*

NOT APPLICABLEVaginalLaparoscopicOpen (abdominal incision)
Reason for Hysterectomy*

NOT APPLICABLEEndometriosisAdenomyosisBenign uteral tumours or uterine fibroidsHeavy bleedingPainful crampsPelvic inflammatory diseasePre - cancerous cellsCancer signs on ovaries/uterus/cervixUterine prolapseChronic pelvic painHyperplasiaOther
Is there anything further you feel I should know about your health and wellbeing?*
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.
I confirm that I have provided details of all known conditions and history. If anything changes, I agree to keep my practitioner updated before any future appointments (Please sign or TYPE YOUR NAME IN CAPITALS BELOW)
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Date*

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