Name
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First Name
Last Name
Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
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Marital Status and No. of Children
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Hobbies and Recreational Activities
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What do you regularly do in your spare time, such as reading, dancing, running, martial arts
Have you had a massage before?
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Please tick any that apply to you:
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If needed, please use the box below to include more details.
Do you need to add any more details to the above conditions?
Describe any stress occurring at present
Does this condition interfere with sleep?
Work
Relationships
Menstrual and Fertility Conditions
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Please tick all that apply
Symptoms experienced prior to and during menstruation
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Please tick all that apply
How many pregnancies have you had?
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Number of deliveries?
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Dates of each birth
Method of delivery
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Please tick all that you have experienced.
If you have given birth, what was your experience of Pregnancy?
Of Labour and Delivery?
Post-Partum?
What are your feelings towards giving birth?
Current symptoms experienced
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Please tick all that apply.
Are you under treatment for infertility, i.e. IVF?
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Have you had any surgery on your abdomen / lower back?
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Have you had any accidents or traumas?
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Have you had any falls or injuries to your sacrum, tailbone or head?
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Do you have high / low blood pressure?
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Are you allergic or sensitive to any medications, food, essential oils, lotions etc?
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Do you have any contagious skin conditions?
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Is your immune system prone to infections, such as colds, sore throat etc?
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Do you have, or have you had, respiratory or heart conditions?
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Are there any other relevant health conditions or injuries not mentioned?
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If you have answered Yes to any of the above, please give us some brief details below.
How do you feel about yourself and where you are at right now?
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If possible, please describe the most negative emotion you experience and when do you most often feel this emotion?
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Have you witnessed or experienced any of the following?
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Please tick all that apply.
What changes would you like to achieve in the next 6 months?
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What changes would you like to achieve in the next 12 months?
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Suzanne Becker therapies may use the following therapies in your treatment: Massage therapy including Swedish Massage, Deep Tissue Massage, Trigger Point Release, Myofascial release, Joint Mobilisation, Reflexology, Manual Lymphatic Drainage, Stretches, Mobilisation, Muscle Energy Techniques, Fertility and Womb health Massage Therapies and Advanced Pregnancy massage. There is always some risk associated with any treatment. Below is a list of potential risks associated with the therapies listed. The best way to reduce the chance of risk occurring is to answer all the questions about your health fully and honestly. The therapist will explain the treatment before they commence but you must ask if you want further explanation or have specific questions. PLEASE REFER TO THE TABLE OF RISKS BELOW, AND INDICATE YOUR CONSENT, OR CONSENT WITH CONDITIONS TO THE RISKS.
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Please specify here the Risks that you would like to add a condition to and what that is.
Please write 'none' if you consent to all the risks in the table below.
PRIVACY POLICY. It may be necessary to discuss your condition and/or treatment with your Doctor, Physiotherapist or referring practitioner. You understand that you have a right to request a copy of the Privacy Policy from the therapist/practice. Do you agree to allow discussions or information to be passed to or between health professionals for the purpose of improving your wellbeing?
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TERMS & CONDITIONS
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I understand that the aforementioned is possible significant risks and complications specific to my individual circumstances that may have a bearing upon my decision to proceed with the proposed treatment.
The therapist has explained the treatment options to me and will discuss with me during the treatment if he/she makes any further changes to the treatment. The therapist has explained to me the associated risks and possible side effects with this treatment and any potential risks or outcomes if the treatment is changed.
The therapist has explained to me that I have the right to refuse treatment or changes to the treatment and that she or I have the right to stop the massage at any time. I understand that I have the right to ask for further information on treatments that include the breast, buttock and groin areas and refuse treatment of these areas at any time.
I have the following points of concern and have advised the therapist prior to treatment (e.g. do not massage the abdomen or feet).
Please tick the boxes as appropriate.
If you have any further comments or notes, please add them here.
