Remedial Massage Pre-Screening

Before your remedial massage at Inspired Movement Practise, it’s important to complete a pre-screening form. Here’s why this step is essential:

1. Your Health and Safety

The form helps us understand any medical conditions, injuries, or allergies you may have. This ensures that the massage we provide is safe for you and won’t cause any harm.

2. Personalized Treatment

By sharing your medical history and current health status, we can tailor the massage to address your specific needs. This means the treatment will be more effective in targeting areas of concern or pain.

3. Informed Consent

The information you provide allows us to discuss any potential risks and benefits with you. This ensures you fully understand the treatment and can consent with confidence, knowing what to expect.

4. Legal Protection

The form also serves as a legal document, recording your health information and consent for treatment. This protects both you and Aerofit Studio Pty Ltd trading as Inspired Movement Practise in case of any issues that might arise during or after the massage.

5. Tracking Your Progress

By updating the form regularly, we can track any changes in your condition and adjust your treatment plan accordingly, ensuring you receive the best possible care.

In short, completing this form is a crucial step in ensuring your massage at Inspired Movement Practise is safe, effective, and personalized to your needs. It also helps protect your well-being throughout the treatment process.

Kate Tyrrell (Katiemac), your treating therapist is registered with Massage and Myotherapy Australia. Registration number 039366. To be and maintain registration with Massage and Myotherapy Australia Kate must meet the maintain 5 areas of compliance (image below). Should you wish to view the Code of Ethics and Standards of Practice please click here.

Member Compliancy Requirements

Image title

First Name *

Last name *

D.O.B *

Address

Street address

City

State

Postcode

Email Address *

Occupation

How would you like to receive appointment reminders? *

EmailSMS

Emergency Contact *

Private Health Fund *

Please provide further details of any conditions you have indicated.

Other medical conditions not listed (past or present).

Are you currently on any medications? This includes Aspirin, Ibuprofen and supplements etc.

YesNo

Detail

Past or Recent surgeries?

Have you had a remedial massage before?

YesNo

If yes, how long ago and what was the reason for it?

What are your current complaints or injuries?

Site/ Location?

Onset (When did this complaint arise)

Was there a MOI (Mechanism Of Injury)?

List any activities that are limited by your current condition i.e. work, sports, sleep etc

List your self care activities i.e. stretching, exercise and ways that you reduce stress

On the diagram below identify where your current symptoms are by circling the area and marking it with a;

P = Pain S = Stiffness JT = Joint pain N = Numbness & Tingling

Body diagram

Clear drawing

Consent for Treatment

I understand that:

▪ This is a massage treatment and is not a medical or allied health treatment (physiotherapy, osteopathy, chiropractic)

▪ I have viewed the therapists’ qualifications

▪ The risks specific to my individual circumstances may have a bearing on my decision to proceed with the proposed treatment

▪ The therapist reviewed my health history before treatment commenced

▪ The therapist explained that the physical assessment I received may involve partial undressing and may require the therapist to palpate (touch) the area(s) of my body relevant to my presenting condition

▪ The therapist explained the treatment options to me and has given me choice

▪ The therapist explained the associated risk and possible side effects with the treatment options as described

▪ The therapist discussed the massage procedures, the areas of the body to be treated, the undressing and dressing procedures, the draping procedures and the positioning on the table for and during treatment

▪ The therapist established that the treatment session will be stopped should the treatment as first agreed to, require modification. The therapist will explain the reason for the change and any risks and/or side effects as a result of the change

▪ I can ask any questions in regard to any modification to the treatment plan. I should be totally comfortable with the explanation and reasoning for the change before consenting to the modification to the initial treatment plan

▪ The therapist has explained that I have the right to refuse treatment, to make changes to the treatment and to stop the massage at any time

▪ I have the right to request evidence for treatment that may include the abdomen, anterior and lateral chest, and buttock and / or groin areas. I understand I have the right to refuse treatment of these areas

▪ If I agree to treatment to any of the areas mentioned in the point above, I may be requested, by the therapist, to complete a consent form relevant to those areas

Do you consent to treatment *

Yes

Please sign as Client/Patient or Parent/Guardian *

Clear

Date *

All information collected in this document is private, secure and encrypted within Inspired Movement Practice's google workspace and Snapforms. Clinical information is stored electronically, in a confidential manner. Communication, unless otherwise specified, between client and therapist shall remain confidential.