Information

Private Health Funds Are Now Available At Bliss Thai Massage & Beauty Therapy.

Please note for all Private Health Insurance Claims you must schedule an appointment with one of our Health Fund Providers to make a claim. Unfortunately, Hicaps is no longer available for on the spot claims, However, we can issue you out a written receipt to claim online or directly via your Health Fund.

If you require any further information please do not hesitate to contact our reception on (03)9379-6883. Only Remedial Massage & Myotherapy Treatments are claimable on Private Health Insurance. All other treatments available within our clinic are not claimable.

All claims are made based on the full price of the treatment and cannot be Discounted at all. Please see our price list Click Here The following Health Fund Companies Are NOT AVAILABLE:

Bupa (NOT AVAILABLE)
Defence Health (NOT AVAILABLE)
medibank_logoMedibank Private (NOT AVAILABLE)

Medical History Form

All (*) Asterisk marked fields must be filled in

YOUR HEALTH FUND :*
MEMBERSHIP NUMBER :*
What number are you listed on the card? Patient ID :*
Full Name:*
DOB:*
Occupation :*
Address :*
Postcode :*
Phone/Mobile :*
Email :*
Emergency contact :
Have you had a massage before? Yes/No If yes, please specify :
Current Medications( including non-prescription) :
Allergies? :
Regular Hobbies/Sports/Activities :
What is your primary complaint? :
Can you describe it? :
Dull
Sharp
Shooting
Achy
Numb
Tingling
Stiff
Pain Scale(1-10) :
Does it radiate anywhere? :
Does anything aggravate your symptoms? :
Does anything relieve your symptoms? :
When did your symptoms begin? :
Have they changed & how? :
Is this condition interfering with :
work
Sleep
Daily Routine
Activities
(please explain) :
Have you seen any other health care practitioner concerning this complaint?
Medical Dr.
Chiropractor
Physiotherapist
Massage Therapist
Other
Have they provided results? :
Surgery/injuries/hospitalization: (date, past & current symptoms) :
Do you have any internal pins/wires/artificial joints? :
Yes
No
Please click on body part on the diagram below to highlight any areas of pain or discomfort you are experiencing
img

Please check all that apply.

Head/Neck

Headache
Migraine
Visual Disturbances
Contact lenses/glasses
Earaches
Hearing Problems
Jaw Pain/Dental Problems
Whiplash

Digestive/Urinary

Difficult Digestion
Constipation
Liver / Gallbladder
Kidney / Urinary
Diabetes(Type & Onset)
Hypoglycemia
Crohn’s disease
Irritable bowl
Ulcers

Muscle/Joints

Neck
Low back
Mid back
Upper back
Shoulder
Hip
Knee
Ankle
Other

Cardiovascular

High blood pressure
Low blood pressure
Chronic Congestive
Heart Failure
Poor circulation
Heart disease
Phlebities
Varicose Veins
Stroke
Heart attack
Pacemaker
Arteriosclerosis
Irregular heart beat

Skin

Bruise easily
Eczema
Psoriasis
Sensitivity
Skin condition
(please specify)
Loss of sensation
(describe)
Athlete’s foot
Cold sores
Plantar warts

Female

Menstrual problems
Pregnancy Due date
Menopausal problems
Gynaecological conditions

Other

Hemophiliac
Epilepsy
Cancer

Respiratory

Asthma
Chronic cough
Shortness of breath
Bronchitis
Emphysema
Smoker

Infectious conditions

Tuberculosis
AIDA/HIV
Hepatitis
Type
Infectious skin
condition(s)
Any recent injury/ accident? :
How is your general health? :
Additional Information :
I*, (print name) understand that the massage I receive is provided for the basic
purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this massage session, I will immediately inform the therapist. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I affirm that I have stated all my known medical conditions, and answered all questions honestly.

Consent for Dry Needling

Signature (Draw Signature Here) : *
Date :*