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Physiotherapy, Massage & Advanced Aesthetics

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Medical intake form

Medical intake form

Physiotherapy & Massage — Medical Intake Form

Please do not fill this out unless requested to.

Information about health and medical history is requested to identify any precautions or contraindications and to support safe, appropriate treatment planning. The information provided will form part of the client’s confidential clinical record and will be stored securely in accordance with data protection requirements. It will be used only in connection with the client’s care. Where input from another medical or healthcare professional may be beneficial, relevant information will be shared only with the client’s knowledge and consent.

Please complete all relevant sections. Fields marked * are required.

Thank you for your submission.

We will be in touch shortly.

Personal Details

Full name *(required)

Date of birth (DD/MM/YYYY) *(required)

Mobile number *(required)

Email address *(required)

Home address / postcode

Occupation

Emergency contact name

Emergency contact number

GP surgery *(required)

How did you hear about us?

Reason for Treatment

Main problem or reason for attending *(required)

Area affected and which side *(required)

When did it start? *(required)

How did it start?

Diagnosis, if known

Symptoms – tick all that apply

Pain Stiffness Weakness Numbness or tingling Swelling Reduced movement Headache Other

Pain/symptom level now (0–10)

How often are symptoms present?

What makes it worse?

What makes it better?

How does it affect daily activities, work, sleep or exercise? *(required)

Previous treatment, tests, scans or relevant medical advice

What would you like to achieve from treatment? *(required)

Relevant Medical History

Please tick all that apply and give details below.

Medical conditions – tick all that apply

Heart condition/angina High or low blood pressure/fainting DVT/PE or blood clot Bleeding disorder/easy bruising Blood-thinning medication Diabetes/reduced sensation Epilepsy/neurological condition Osteoporosis/fracture Arthritis/joint replacement Cancer/current treatment Respiratory condition/asthma Recent surgery/hospital admission Pregnant/postnatal Fever/infection/current illness Skin condition/rash/open wound Recent significant injury Unexplained weight loss/night sweats New weakness/numbness or bladder/bowel changes Other medical condition

Details of any conditions ticked above

Current medication and supplements *(required)

Allergies or sensitivities *(required)

Any other relevant health information

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