Client Questionaire Full Name Phone (mobile) Phone (landline) Email * Date Of Birth Address Suburb Postcode What Exercise do you currently do? Current Exercise Frequency Rarely (once per month) Sometimes (once per week) Regularly (2 or 3 times per week) Often (4 or more times per week) Occupation How did you hear about us? Private Health Insurer Is Massage Covered by your Private Health? Yes No Unsure Is Naturopathy Covered by your Private Health? Yes No Unsure Doctor Or Other Care Giver Name Doctor Or Other Care Giver Phone How Often Do You Get a Massage? This is the first time Rarely (around once per year) Sometimes (2 – 4 times per year) Regularly (4-11 times per year) Often (12 or more times per year) Please Mark If You Have Any Of The Following High/Low Blood Pressure Thrombosis (blood clots) Osteoporosis Illness, accidents or surgery in the last 5 years Fever Allergy to Oils, Smells, Lotions Skin Conditions Varicose Veins Headaches Bruising Localised Pain Broken Bones Numbness Pain while lying prone or supine (face down or face up) Are you Pregnant or Breastfeeding No Yes, Pregnant Yes, Breast Feeding Yes, Both (if pregnant) How Many Weeks Pregnant (if pregnant) what is your due date? (if pregnant) Medical Caregivers Where do you feel pain or discomfort What makes the pain better or worse List Current Medications