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DDS Chinese Massage Torquay
1. CLIENT DETAILS
Full Name
*
DOB
*
Gender
*
A
Male
B
Female
C
Other
Address
*
Postcode
*
Phone
*
Email
*
Emergency Contact
*
Relationship
*
Emergency Phone
*
2. PRIVATE HEALTH INSURANCE (HICAPS)
Health Fund
*
Membership No.
*
Patient ID / Policy No.
*
Claiming through HICAPS?
*
A
Yes
B
No
Referral Type
*
A
GP
B
Specialist
C
Self
D
Other
3. REASON FOR VISIT
What is the main reason for your visit today?
*
Neck Pain
Headache
Shoulder Pain
Sports Injury
Upper Back Pain
Postural / Muscle Tension
Lower Back Pain
Stress
Hip Pain
Fatigue
Knee Pain
Other
Sciatica / Nerve Pain
Pain Level
*
0
1
2
3
4
5
6
7
8
9
10
Duration
*
A
Today
B
Less than 1 week
C
1 - 4 weeks
D
1 - 3 months
E
More than 3 months
Please indicate areas of discomfort
*
DETAILED BODY ASSESSMENT
Please indicate the nature of your discomfort for each area:
Pain
Stiffness
Numbness
*
Neck
Shoulders
Upper Back
Lower Back
Hips
Knees
Arms & Hands
Legs & Feet
4. MEDICAL HISTORY
Please tick all that apply
*
High Blood Pressure
Pregnancy
Varicose Veins
Heart Disease
Recent Surgery
Deep Vein Thrombosis (DVT)
Diabetes
Fracture
Neurological Disorder
Osteoporosis
Pacemaker
Epilepsy
Arthritis
Blood Thinners
Allergies
Cancer
Skin Infection / Condition
Other
Please list current medications or supplements:
*
5. CONTRAINDICATIONS / CURRENT SYMPTOMS
Please tick all that apply
*
Fever / Flu
Dizziness / Fainting
Open Wounds
Shortness of Breath
Bruising / Swelling
Recent Accident / Injury
Numbness / Tingling
None
Other symptoms or conditions not listed:
*
6. TREATMENT PREFERENCE
Preferred Pressure:
*
A
Light
B
Medium
C
Firm
D
Deep
Areas to Avoid:
*
7. CONSENT & DECLARATION
I understand and agree to the following:
*
I understand remedial massage is not a substitute for medical treatment or advice.
I consent to receiving remedial massage treatment.
I authorise DDS Chinese Massage to process my claim through HICAPS for eligible private health insurance rebates on the day.
I understand that any rebate is subject to my health fund's policy and I am responsible for any gap or out-of-pocket expenses.
8. SIGNATURE
Client Signature:
*
Client Signature
Date:
*
THERAPIST USE ONLY
Provider No.:
*
Therapist Signature:
*
Therapist Signature
Submit
