Aurora Bodywork Client Intake Form

Client Intake Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Please ensure you read the form thoroughly, and complete all relevant areas. In order for your massage to commence on time, please return your completed form to Aurora Bodywork at least 24 hours prior to your appointment, so travel time and session can be appropriately planned.

If you have any difficulties completing the form, please contact Kate at hellokate@aurorabodywork.com.au for assistance.

*PLEASE NOTE: All massage therapy services by Aurora Bodywork are provided on a mobile basis: please disregard the location information on the confirmation email via the Fresha booking platform.*
Date*

DayMonthYear
Name*

Preferred first name - what do you want me to call you? There's a section further down for your formal name for insurance claiming purposes.Last/ Family name
Name*

First NameLast Name
Your pronouns
Not required, but if you'd like to share them, please do!
Birth Date

DayMonthYear
Date of birth*
Sometimes it's just easier to type it out rather than scroll through the dates!
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number

Area CodePhone Number
Existing conditions and medications
Please include all conditions/ medications. Some conditions and medications are contraindicated for massage therapy, either entirely or partially, and if this is the case, I will contact you prior to your appointment to discuss this further to ensure your safety.
Pregnant clients only: if you are having a prenatal massage, please indicate how many weeks you will be for your first massage, and any issues (nausea, sensitivity to smell, sciatica, carpal tunnel syndrome, etc). If you are in the high-risk category, or >34 weeks, please obtain clearance from your obstetrician.
Allergies
Please note I usually use pure jojoba oil, with or without essential oils. I also have a nut oil mixture that is used occasionally. Arrangements can be made to ensure your massage is free of allergens if you are affected.
Private Health Fund
Please note that AustUnity and CBHS Health are the only funds which clearly state they cover mobile massage. I do have provider numbers for most funds, excluding BUPA and HCF, and I am happy for you to contact me for it so you can check with your fund. You are welcome to discuss this issue directly with your fund to request cover for mobile massage, especially if you have difficulties attending a clinic.
Name on private health insurance policy (if applicable)
Name listed on your insurance policy (if you can claim) - if different to your preferred name.
Emergency Contact and phone number*
List any areas of discomfort/ limitation or pain if applicable:
Do you know when the onset of discomfort/limitation or pain occurred? If yes, please elaborate if you wish to:
Frequency - please select the most accurate

ConstantOff/OnAt RestWith ActivityOther
At what time of day is the pain at its worse?

MorningAfternoonEveningDuring SleepOther
Have you ever injured this area before?
Have you ever been in an accident (automobile, work, falls, etc.) ?
List all related treatments received for this injury.
Is there anything that you do that creates, increases or decreases pain?
Please provide the details (name, practice, phone number) of your General Practitioner/ primary care provider*
The following provides a checklist of any physical limitations/ injuries you may be experiencing. If it makes life easier for you, please feel free to complete it - if not, you can skip it entirely, and go straight to the client agreement.
Head

TemplesForeheadTop of headAround the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther
Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther
Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed osteoarthritisCan't raise arm above shoulder levelCan't raise arm over headOther
Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed osteoarthritisLoss of grip strengthOther
Mid-Back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther
Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther
Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed osteoarthritisOther
Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther
Is there anything else you need me to know prior to your massage appointment?
Please include any cultural considerations/ requirements, concerns you may have or adjustments that might need to be made during the treatment so you feel more comfortable, and where to park at your place if you live in a complex. If parking needs to be paid for, please be aware this amount will be added to your massage session fee.
How did you hear about Aurora Bodywork (if via word of mouth, please specify who, so I can thank them personally!)?*
Massage policy and client agreement*
Signature

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