Pre fill form

Care Experience Convenience

Welcome
Contact
- About Benedict
- Pre fill form
Massage Styles
- Massage & The Elderly
Pricing
- Gift Certificates

If you wish to pre fill a Health Questionnaire to save time on the day of your appointment, please use the form below:
It is necessary to assess and be made aware of your health conditions so that we can provide a safe and effective treatment. This is kept confidential and only shared with other Health Care Practitioners if required.

Confidential Health Questionnaire

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Don't worry, no spam. Used to share relevant documents as required

Date of birth *

at least year of birth please

Please tick, add details if necessary for the following: *

Shortness of breath or chest pain (Asthma, COPD, Emphysema etc) High or low blood pressure Heart conditions/stroke (hemiplegia, Angina) High cholesterol Fluid retention (oedema, inflammation) Diabetes (type I, II, gestational) Pregnant (which trimester) Loss of balance/recent falls/dizziness/fainting Cancer Infectious diseases Allergies Musculoskeletal injuries (eg: strains sprains, whiplash etc) Joint conditions (eg: TMJ, Osteoarthritis, Herniated Disc) Nerve Conditions (eg: Sciatica, Carpal tunnel) Central Nervous System (eg:Parkinson's, MS, seizures, migraines, ) Gastrointestinal Conditions (IBS, chronic constipation, bloating) Autoimmune or Endocrine conditions (eg: Hypothyroidism, rheumatoid arthritis)

Further details of ticked items above *

Accidents/injuries with approximate dates *

(workplace, motor vehicle accidents, recreational etc)

Current Medications *

This is to help inform of possible side effects and treatment strategies used.

Hospitalization/Surgeries with approximate dates *

Please list all surgeries even done years ago as long lasting effects such as scar tissue, compensatory movement patterns etc may be relevant to your treatment.

Current Physical Activity *

By clicking submit, I understand the information provided is true and accurate to the best of my ability. *

Submit