Client Entry Form Question Title * 1. Full Name Question Title * 2. Date of Birth Question Title * 3. Home Address Street name and number Suburb Postcode Question Title * 4. Phone Number Question Title * 5. E-mail Question Title * 6. Are there any areas you would like to focus on during this session? (physical, emotional, mental, spiritual)Are there any areas of concern or soreness? Question Title * 7. If you are seeing me for scar treatment, please fill in as many details as possible about it. LocationSizeHow you got itHow long ago you got itAny physical discomfort it is causing youAny other additional information that may be relevant Question Title * 8. Do you have any of the following conditions? Stress Recurring injury Contagious disease Cancer Neck/spine injury Herpes Wear contact lenses Arthritis Osteoporosis Joint swelling Abdominal disorder Numbness Infectious disease Recent surgery (in the last 5 years) Fatigue Allergies Shingles Back pain RSI HIV+/AIDS Heart condition Epilepsy or seizures Varicose veins Respiratory disorder Stabbing pains Recent accidents (in the last 2 years) Sensitive to touch Insomnia Skin infections Diabetes Pregnant (Please fill in a Pregnant client form instead) Joint replacement Dizzy spells Low blood pressure Frequent headaches Bruise easily Depression Circulation disorder High blood pressure Blood Clots Other medical condition None of the above Question Title * 9. Your current life stress level 1(LOW) - 10(HIGH) LOW SOMEWHAT MANAGABLE HIGH Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 10. ARE YOU CURRENTLY RECEIVING ANY OF THE FOLLOWING TREATMENTS? Physiotherapy Chiropractic Remedial massage Naturopathy Acupuncture Osteopath Shamanic healing Other (please specify) None of the above Question Title * 11. ARE YOU CURRENTLY BEING TREATED FOR ANY MEDICAL CONDITIONS? Yes No Other (please specify) None of the above Question Title * 12. Are you currently taking any prescribed medications OR have any Allergies? (Please specify) Yes No None of the above Other (please specify) Question Title * 13. WHAT WHOULD YOU LIKE TO ACHIEVE FROM YOUR SESSION TODAY? Question Title * 14. ARE YOU CURRENTLY EXPERIENCING ANY PAIN OR STRUGGLE? Emotional Physical Spiritual Mental Other (please specify) None of the above Question Title * 15. WHAT IS YOUR INTENTION FOR TODAY? (If I had a magic wand what do you wish for?) Question Title * 16. Do you allow me to make any photos/filming for marketing purposes Yes No Question Title * 17. A Lomi Lomi treatment traditionally attends to the whole body, head to toe to fingertips (with the exception of genitalia). If you have any concerns, please discuss them prior to the commencement of your massage.I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular & emotional tension. When I experience any pain or discomfort during the session, if necessary, I will inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that Massage Therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Massage should not be performed under certain medical conditions, as such, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile prior to the session and understand that there shall be no liability on the Massage Therapists part should I fail to do so. I also understand that the Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated. I understand Question Title * 18. Release and Indemnity to the Lomi Lomi PractitionerIN CONSIDERATION of my payment for participating in the activity provided by Tatiana Price (Embraced In Care) (and the extent that the same may be precluded by statute) I ACKNOWLEDGE AND AGREE TO RELEASE AND INDEMNIFY the Lomi Lomi Practictioner as follows:I participate in the activity at my own risk and responsibility.I release, indemnify and hold harmless the Lomi Lomi Practitioner from and againstall actions or claims that may be made by me or on my behalf by other parties in respect of or occurring from an injury, loss, damage, or death caused to me or my property whether from negligence, breach of contract or in any way whatsoever or any liability that results from the breach of an express or applied warrant that the treatment will be rendered with responsible care or skill.In the event that I am injured or my property damaged, it will bring no claim, legal or otherwise, against the Lomi Lomi Practitioner in respect of the injury or death.By signing this document I acknowledge that I have read and understood all content and know that it affects my legal rights.Your therapist works within the Australian Code of Conduct for Healthcare Workers and adheres to both the COAG Health Council Communique and the National Code of Conduct 2015.We provide our our treatments in accordance of ‘The IICT Code of Ethics’.Copies of these codes are available through the following link: https://1drv.ms/u/s!AkpAwz9BGcW2qcNwkraZi4cAbXeVWA?e=tRPu9aor copies available upon request. I understand Question Title * 19. Clients Name and Date Question Title * 20. Emergency contact details Name Phone Number Done
