TSMT — Intake & Consent Form

This form combines your health history, general consent, dry needling consent, and infrared sauna consent into a single document. All information is collected and stored in strict confidence in accordance with the Privacy and Data Protection Act 2014 (Vic) and the Health Records Act 2001. Records will not be distributed or discussed with a third party without your express permission.

Practice: Thomas Stratton's Musculoskeletal Therapies · ABN 49 582 562 430
Address: 1 Evesham Drive, Point Cook VIC 3030 · Phone: 0412 054 020

Section 1 — Client Details

Please notify your therapist if any of these details change between appointments.

Date of Completion *

Biological Sex *(as recorded at birth)

First Name *

Last Name *

Preferred Name

If you go by a name other than your legal first name.

Date of Birth *

Phone *

Email Address *

Occupation *

Nature of Work *

The physical demands of your typical working day.

TAC / WorkCover / Third-Party Claim

If treatment will be billed through a compensation scheme.

Private Health Fund

Membership Number

Home Address *

How did you hear about TSMT?

General Practitioner

Providing your GP's details allows us to coordinate care and communicate findings when clinically appropriate.

GP / Doctor Name

Clinic / Practice Name

GP Phone

Previous Treatment History

Understanding your prior treatment experience helps us better tailor the approach for your first session.

Have you previously received myotherapy or remedial massage? *

Yes No — this is my first time

Are there any previous treatments or techniques that you found particularly helpful — or unhelpful?

Section 2 — Emergency Contact

Please provide the details of someone we can contact in the event of an emergency.

Contact First Name *

Contact Last Name *

Contact Phone *

Contact Email

Relationship *

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Section 3 — Current Medications

List any prescription or over-the-counter medications you are currently taking, including dosage and reason for use. Leave blank if none.

Medications, dosage & reason

Section 4 — Medical Health History

Please tick all items that currently apply or have applied in the past. The more detail you provide, the more effectively your treatment can be tailored.

Do you have any known allergies? *

Yes No

If yes, please describe below.

General Health

Musculoskeletal

Skin Conditions

Eye, Ear, Nose & Throat

Gastrointestinal

Genitourinary

Cardiovascular

Respiratory

Female Health (if applicable)

General Medical Conditions

Have you been hospitalised in the last 5 years? *

Yes No

Have you had any broken bones, serious strains, or sprains? *

Yes No

Have you been involved in a motor vehicle accident? *

Yes No

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Section 5 — Current Complaint

The following questions assist in forming a clinical assessment prior to your appointment. The more detail you provide, the more effectively your session can be tailored.

Describe your current complaints in detail *

Please list all symptoms in order of severity — most significant first.

When did the symptoms first appear?

Was the onset sudden or gradual? Has it been improving, worsening, or unchanged since onset?

What appeared to cause the symptoms?

E.g. specific injury, repetitive movement, prolonged posture, gradual onset without a clear cause.

Is the pain intermittent or constant? *

Intermittent — comes and goes Constant — always present Variable — changes throughout the day

Does the pain stay localised or spread? *

Localised — stays in one area Radiates — spreads to other areas

How would you describe the quality of the pain or discomfort?

E.g. dull ache, sharp, burning, shooting, throbbing, tingling, numbness, tender to touch.

Have you noticed any reduction in range of motion or mobility?

What makes the symptoms better or worse?

E.g. rest, heat, cold, specific movements, prolonged postures, time of day, stress, physical activity.

Any other signs or symptoms associated with this complaint?

Impact & Prior Management

Understanding how your condition affects your daily life, and what has already been tried, is an essential part of clinical assessment.

Has this condition affected your work or daily activities? *

Yes No

Has this condition affected your sleep? *

No — sleep is unaffected Difficulty falling asleep due to pain Waking during the night due to pain Cannot find a comfortable sleeping position

Have you sought any treatment for this complaint previously? *

Yes No

Have you seen a doctor, specialist, or had imaging for this complaint? *

Yes No

What are your goals for treatment? *

What would a successful outcome look like for you?

Pain Rating — Current Overall State *

Select a number from 1 (minimal discomfort) to 10 (worst pain imaginable).

1 — Minimal10 — Worst imaginable

Upload Medical Imaging, Reports, or Referral Documents

X-ray reports, MRI/ultrasound reports, referral letters, or clinical notes. PDF, JPG, PNG accepted.

📎

Drag and drop files here, or click to browse

Maximum 5 files · PDF, JPG, PNG

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Section 6 — Informed Consent: Myotherapy & Remedial Massage

Please read the declaration below in full before signing. Your signature confirms understanding and agreement.

First Name — Client or Legal Guardian *

Last Name *

Signature — Client or Legal Guardian *

Sign using mouse, trackpad, or finger

Date of Signature *

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Section 7 — Dry Needling Consent Optional

Complete this section if dry needling is planned as part of your treatment. If dry needling is not being used, you may proceed to the next page.

Dry Needling — Contraindications

Please select any that currently apply. This information may modify or preclude the use of dry needling.

By signing below, I confirm that I have read and understood the definition, risks, and contraindications associated with dry needling. I consent to its use by Thomas A. Stratton and acknowledge that I may request discontinuation at any moment during treatment.

First Name *

Last Name *

Signature — Dry Needling Consent *

Sign using mouse, trackpad, or finger

Date *

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Section 8 — Infrared Sauna Consent Optional

Complete this section if you are using or intend to use the infrared sauna. If sauna use is not applicable, proceed to submit.

I confirm that I have read and understood the therapeutic overview and potential benefits above.

I agree to comply fully with the attire and hygiene protocols described above.

I confirm my understanding of hydration and medical safety requirements, and accept responsibility for disclosing relevant conditions.

I acknowledge and consent to security camera surveillance in shared clinic areas, and accept responsibility for appropriate sauna use and liability for any damage from my misuse.

Final Declaration & Signature

By signing below, you confirm that you have carefully read and understood all applicable sections of this form, that you have had the opportunity to ask questions, and that you voluntarily provide your informed consent for treatment and sauna use as described.

First Name *

Last Name *

Email Address *

Date *

Final Signature *

Sign using mouse, trackpad, or finger

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Section 1 — Client Details

General Practitioner

Previous Treatment History

Section 2 — Emergency Contact

Section 3 — Current Medications

Section 4 — Medical Health History

Section 5 — Current Complaint

Impact & Prior Management

Section 6 — Informed Consent: Myotherapy & Remedial Massage

About Your Therapist

By Signing Below You Confirm and Agree

Section 7 — Dry Needling Consent Optional

Definition

Risks Associated with Dry Needling

Dry Needling — Contraindications

Section 8 — Infrared Sauna Consent Optional

Therapeutic Overview & Potential Benefits

Attire & Hygiene Protocols

Hydration, Health Considerations & Medical Responsibility

Security Camera Notice

Appropriate Use & Liability for Damages

Final Declaration & Signature

Thank you.