Confidential

Client Intake & Health History

Please complete this form before your first appointment. All information is treated in the strictest confidence.

Section 1

Your Details

Full Name *

Date of Birth *

Phone *

Email Address *

Address *

Emergency Contact Name *

Emergency Contact Phone *

Section 3

Health Information

Please tick any that apply

Heart or circulatory condition

High blood pressure

Diabetes

Epilepsy or seizures

Pregnancy

Blood-thinning medication or bleeding disorder

Implanted medical device (pacemaker, defibrillator, neurostimulator, etc.)

History of blood clots, recent heart attack, or unstable cardiac condition

Recent surgery or injury

Recent fainting, dizziness, or adverse reaction to treatment

Active infection, fever, or contagious illness

Skin condition, rash, bruise, or infection in the treatment area

Other significant medical condition

Allergies — list any known allergies (food, medications, materials, etc.)

Medications, herbs or supplements — include dosage if known

Recent injuries, surgery, or painful areas — include approximate dates

Section 4

Treatment Preferences

Pressure Preference

LightModerateFirm

Areas to avoid — list any body areas you would like us to avoid

Sensitivity to oils, creams or lotions — note any products or ingredients to avoid

Section 5

Consent & Acknowledgement

I understand that acupuncture, massage, and vibroacoustic therapy may produce temporary effects including soreness, bruising, light-headedness, fatigue, emotional release, or relaxation responses.

I confirm that I have disclosed all relevant health information, including implanted medical devices, pregnancy, epilepsy, recent surgery, or cardiovascular concerns.

I understand that these therapies are complementary in nature and are not a substitute for diagnosis or treatment from a GP or other medical professional. I may ask questions, pause, or stop treatment at any time.

If sauna, steam, or hot tub facilities are included in my package, I understand that use of these facilities is at my own risk and I will seek medical advice if I have any concerns.

I confirm that the information provided is accurate and complete to the best of my knowledge. *

Print Name (Signature) *

Date *

Parent / Guardian (if applicable)

Guardian Print Name

Date

Privacy Notice

How we handle your data: The information you provide will be used to assess your suitability for treatment, provide safe and effective care, manage appointments and records, and contact you about your treatment where necessary.

Your personal data will be stored securely and only accessed for the purposes of your care or business administration. Information will not be shared with third parties unless required for your care, required by law, or with your permission.