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info@nswremedialmassage.com.au

Client Intake Form

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Address

Occupation

Emergency Contact /Name & Phone Number

Are you claiming Health Fund ?

Yes

No

If yes, which Fund?

Membership No.

Where do you feel pain or tightness?

Head/Headache

Neck

Shoulder – Left

Shoulder – Right

Arm – Left

Arm – Right

Elbow - Left

Elbow - Right

Wrist/Hand - Left

Wrist/Hand - Right

Upper Back

Lower Back

Leg – Left

Leg – Right

Knee - Left

Knee - Right

Ankle/Foot - Left

Ankle/Foot - Right

Jaw/Face

Have you ever been diagnosed with any of the following?

Heart condition

High/Low blood pressure

Diabetes

Osteoporosis

Recent surgery

Consent & Signature

I confirm that the information provided is accurate and I give my consent to receive remedial massage therapy.

Date picker

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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