24 Nairn Street, Spreydon, Christchurch 8024

New Client Intake Form for Bodyworks

Thank you for booking with Bodyworks Massage Therapy. As a new client it’s important that we learn a little more about you and how we can help, so we’d appreciate if you could fill out our Client Intake Form below before your appointment. Once you complete the form, there’s no need to arrive early, just arrive at your scheduled time.

 

Client Intake Form

Contact details

Firstname:
Surname:
Address:
Suburb:
Town/City:
Email:
Mobile Ph:
Home Ph:
Work Ph:
Date of Birth:
Occupation/Main work:  
How did you hear about us?
If someone referred you, who was it?  
What sport/exercise/ physical activity do you do and how often?:

If you are wanting pure relaxation massage from us, then you can skip the next section and go to the bottom of the page, however you might like to complete the next section so we know where to focus.

Present Problem/Condition

What/where is your current main problem or condition?
Is it getting progressively worse?
Yes No Comes & goes
How much is pain interfering with your day-to-day activities and quality of life?
0 = not at all, 10 = completely
What aggravates your condition?
What have you done to get any relief?
Has it been medically diagnosed? If yes, by whom and what was the diagnosis?
Have you had any surgery? List as many as you can remember with the approx. year
Have you had any accidents or injuries? List as many as you can remember with the approx. year

We collect personal information from you, including contact information about your health history. We collect this information in order to rule out any conditions that may make the massage unsafe and will also help to individually tailor your massage to suit your needs. If you choose not to provide us with your health history, we may be unable to provide massage therapy services. You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you'd like to ask for a copy of your information, or to have it corrected, please contact us at rachel@bodyworksmassage.co.nz. We respect your privacy under the Privacy Act 2020.