General Client Details
Details of Health Professional:
Are you currently experiencing OR ever been diagnosed with any of the following conditions?
Please note the AGE of each of your other children. Please also note the mode of delivery (vaginal or section) for each child, the weight at birth of each child, and report any previous obstetric injuries (tear/episiotomy) or any complications related to each delivery and pregnancy.
Please describe where your pain complaints are. Be as accurate as possible, noting down whether the pain is sharp and shooting or dull, achy and muscular in nature. How long have you had the pain? Are there positions you wish to avoid during your wellbeing therapy session?
Outline easing factors such as rest, ice, heat, certain positions, other therapies etc. Anything that has helped.
Are you best in the morning? Worst in the morning? Do things settle down with movement or get worse with movement? Is there a best time of day for you to attend for wellbeing therapy?
Current Health Status
Please outline if you have any specific preferences regards pressure of manual therapy/massage: LIGHT, MEDIUM, FIRM. Please also note if there is ANY AREA that you do NOT wish to be treated, e.g. abdomen, feet, legs, arms, shoulders, head, neck.
Thank you for taking the time to complete this form!
We really appreciate the time that you put in to completing this form. The information provided will very much help your well-being therapist during your initial consultation.
We rely on your feedback to help us improve our services. Your input is greatly appreciated.