Massage Health History - Chiropractors Geraldton Straight Up Health

YOUR DETAILS

Name*

Title First Last

Preferred Name

Occupation*

Postal Address*

Address Suburb State Postcode

Date of Birth*

Gender*

Male
Female

Mobile Phone*

Home Phone

Work Phone

Email*

We will send you a copy of your answers

Private Health?*

Yes
No

Fund Name*

Member Number*

EMERGENCY CONTACT PERSON

Emergency Contact Name*

First Last

Phone*

Relationship to you*

WHO MAY WE THANK FOR REFERRING YOU?

Source

Name of Referrer*

YOUR HEALTH

At Straight Up Health, we know that symptoms are clues. They are your body’s way of telling you there is a problem. Our job is to look for the cause of your problem. We want to fix the cause, not just quieten down the symptoms. Make sense?

Our mission is to help you understand why you aren’t well, help you to get well and teach you to stay that way. That’s what we do.

*What is your main purpose for a massage?*

*Do you have any health goals you are working towards?*

Are you on any medications?*

Any major health issues in the past? (heart, stroke, diabetes, cancer, surgeries, medical conditions etc.)*

Which part/s of the body are you having troubles with?

How bad is your problem today?*

1=Not bad at all / 10 = Worst possible

How much of your daily activities is it affecting?*

1=None at all / 10 = Affects everything I do

How long has it been since the VERY FIRST TIME you EVER felt this problem?*

Given your last answer, how long do think it is likely to take your body to heal?*

Lots of different stressors contribute to physical problems. Do any of these sound like you?

0 means it’s not an issue, 10 means it’s a really big issue.

Personal/work mental or emotional stress*

Physical work or sport injury*

Exposure to strong chemicals (beauty, industrial, cleaning, smoking)*

Dietary stress (high sugar, high carbs, alcohol, low water, low fat diet)*

Is there anything else you would like to tell us about yourself or your life?

THE BUSINESS END OF THINGS

Payment is due at the time of service. (non-payment on the day will attract a $5.00 account keeping fee). We also have a missed appointment or late cancellation fee. There are often waiting lists to get in to see one of our professionals. If you really can’t make it, please call, email or reply to our text messages so we can reschedule your appointment and make room for someone who may need it badly. We try to be as flexible as possible to help you work it around your life.

Please be courteous at all times to our staff. They will do the same for you. Please feel free to contact us on reception@straightuphealth.com.au if you have any concerns or comments.

We love kids and we will help you with them while you are having your appointment if needed, but please monitor your children’s behaviour while they are here as it isn’t a playground. If they make a mess, please tidy up after them. We have a change table in the toilet area for your convenience as well.

If we are running behind, it’s not because we don’t care, it’s usually because we care too much. Someone might be having a rough day or be in a large amount of pain. We do our best to help each person. Sometimes things are out of our control. If you are concerned about potentially having to wait for your appointment, call us before your time to see how our time line is moving 9964 4205. Again, please be kind to our reception team. They do their best.

Please tick the box if you DO NOT wish to be on our Mailing/Email List

No Thank You

Do we have your permission to email Tax Invoices, Posture pictures and any Clinic/health related information?*

Yes
No