Massage & Movement Therapy Client Intake Form Step 1 of 2 - Client Details 0% Name First Last DOB DD MM YYYY Address Street Address Address Line 2 City ZIP / Postal Code Email Mobile PhoneGP / Primary Health ProviderHealth Fund (if applicable)Select OneBUPAHBAAHMMEDIBANK PRIVATEAUSTRALIAN UNITYNIBHCFCBHSDOCTORS HEALTH FUNDGU HEALTHACA Health Benefits Fund LtdCessnock District Health Benefits FundCUA HealthDefenceFrank HealthGMHBA (Including Frank Health Fund and My Own Health Fund)GMF HealthHBF ( WA Fund)Health.com.auHealth Care Insurance LimitedHealth PartnersHIF WALatrobe Health Services (Federation Health)Mildura District Hospital FundNavy Health FundNurses & Midwives Health Pty LtdOnemedifundPeoplecare Health InsurancePhoenix Health FundPolice Health FundQueensland Country Health Fund LtdRailway and Transport Fund LtdReserve Bank Health Society LimitedSt Luke’s HealthTeachers Federation HealthTeachers Union HealthTransport HealthWestfundNot ApplicableUnknownOtherHealth Fund (Other)Are you presently taking any medication?*YesNoI Don't KnowPlease explainPlease provide details of any medication that you're taking Musculo/Skeletal ConditionsHeadachesJoint stiffness/swellingSpasms/crampsBroken/fractured bonesStrains/SprainsBack/hip painShoulder, neck, arm, hand painLeg, foot painChest, ribs, abdominal painProblems walkingJaw pain/TMJTendonitisBursitisArthritisOsteoporosisScoliosisOtherDigestiveIndigestionConstipationIntestinal gas/bloatingDiarrhoeaIrritable bowel syndromeCrohn's DiseaseColitisOtherNervous SystemEpilepsyNeuropathyFatigueSleep disordersCerebral PalsyMSParkinson's DiseaseOtherCirculatory/RespiratoryHeart conditionHigh Blood PressureLow Blood Pressure}low_bpAsthmaChronic Lung DiseaseStrokeSpecial NeedsCancerAnxietyDepressionMigraine headachesAuto-immune disordersChronic PainDiabetesFibromyalgiaOther