Secure client intake

Your health history,
handled with care.

Complete this form before your first treatment, or whenever your health information changes. Your answers are encrypted and available only through Michael’s private dashboard.

Urgent medical concern? This form is not monitored for emergencies. Call 000 or seek appropriate medical care.

About you

Fields marked * are required.

Full name * Date of birth * Pronouns Email * Phone * Home address or suburb * Emergency contact — name, relationship and phone *

Subjective

What brings you in?

Main reason for treatment and your goals * When did it begin, and how has it changed? Pain or discomfort now (0–10) * Previous treatment or advice What makes it worse? What makes it feel better?

I confirm that the information I have provided is accurate and complete to the best of my knowledge, and I will tell Michael about relevant changes. I understand massage may involve touch, pressure and movement. I can ask questions, change or withdraw consent, or stop treatment at any time. I agree to Muscular Remedies collecting and securely storing this health information for assessment, treatment and record keeping, as explained in the privacy notice.

Type your full name as your signature *

Your Objective, Assessment and Plan notes are completed privately by Michael after your treatment.

Form received

Thank you. Your history is saved securely.

Reference:

Michael can review it in the private dashboard before your treatment. No health information has been sent by email.

Return to Muscular Remedies

Your health history,handled with care.

About you

What brings you in?

Health history

Consent and signature

Thank you. Your history is saved securely.

Your health history,
handled with care.