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info@nswremedialmassage.com.au

Client Intake form

Prefix

Full Name

Date of Birth

Nationality

Age

Phone number

E-mail

Address

Occupation

Emergency Contact/ Name & Phone Number

Are you claiming Health Fund? / Which Fund? / Membership No.

Which do you feel pain or tightness?

Head / HeadacheJaw / FaceNeckShoulder - LeftShoulder - RightArm- LeftArm- RightElbow - LeftElbow - RightWrist/ Hand - LeftWrist/ Hand - RightUpper BackLower BackLeg - LeftLeg - RightKnee - LeftKnee - RightAnkle / Foot - LeftAnkle/ Foot - Right

Pain Level Before Massage (0 = No pain, 10 = Most severe)

Have you ever been diagnosed with any of the following?

DiabetesHigh/Low blood pressureHeart diseaseOsteoarthritisChronic back painAsthma

Consent & Signature

I confirm that the information provided is accepted and I give my consent to receive Remedial Massage therapy.

Submitted Date

Signature

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©2025 NSW Remedial Massage. All rights reserved.
Located in Sydney CBD – Thai Remedial Massage using 2 thumbs only, no tools.
Tel: 0422 786 924

Email: info@nswremedialmassage.com.au
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ABN 19 104 038 745

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