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GYROKINESIS® Level 1
GYROTONIC® Level 1
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Guest Trainers at Hara
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Pilates
GYROTONIC® and GYROKINESIS®
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The Hara Difference
FAQs
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Cart
0
Book Now
Group Class
1:1 Session or Massage
Workshops
Workshops
Classes
Group Classes
Quad Classes
1:1 Sessions
Massage
Teacher Training
GYROKINESIS® Level 1
GYROTONIC® Level 1
GYROTONIC® & GYROKINESIS® Continuing Education
Guest Trainers at Hara
Services
Pilates
GYROTONIC® and GYROKINESIS®
Yoga & Yoga Therapy
Dance Coaching & Conditioning Programs
Dance For Parkinsons
About Hara
The Hara Difference
FAQs
New Student Guide
Pricing
How to Pay
Testimonials
Blog
Meet Suzanne
Pilates, Yoga, Gyrotonic Studio in Coffs Harbour NSW
Massage Registration Form
Please complete the below form to help me provide you with the best massage service possible.
PERSONAL DETAILS
Name
*
First Name
Last Name
D.O.B
*
Please click on calendar or field to select date.
MM
DD
YYYY
Email Address
*
Phone
*
(###)
###
####
May we send you emails?
*
Yes
No
May we send you texts?
*
Yes
No
Would you like to subscribe to my monthly newsletter?
*
Yes
No
How did you hear about me?
*
Facebook
Instagram
Word of Mouth
Poster
Newspaper Ad
Web
Other
Address
*
Occupation
Private Health Fund
EMERGENCY CONTACT
Emergency Contact Name
*
Emergency Contact Phone
*
(###)
###
####
Emergency Contact Relationship
*
CURRENT DOCTOR
Current Doctor
First Name
Last Name
Dr Contact Number
(###)
###
####
Other Allied Health Professionals
Do you have a referral from other Health Practitioner?
If yes, please advise who.
MEDICAL HISTORY
Are you taking any medications?
*
If yes, please list.
Any allergies? Oils, lotions, fruit, nuts etc.
*
If yes, please provide details.
Are you pregnant?
If yes, how many months are you? When is your due date?
Are you currently under medical supervision or receiving other medical interventions?
If yes, please describe.
How many hours do you sleep per night?
*
Do you smoke?
*
Yes
No
Do you drink Alcohol?
*
If yes, how many glasses per week.
Your current injuries / illness/ medical conditions. (Last 3 months)
Your previous injuries / illness/ medical conditions. (Last 12 months)
Current Health Concerns.
*
Please select all that apply.
No Current Health Concerns
Abdominal/digestive issues
Allergies
Arthritis
Asthma/lung conditions
Blood Clots
Cancer / Tumours
Chronic Fatigue
Covid Virus
Chronic Pain
Depression
Diabetes
Fatigue
Fibromyalgia
Headaches/Migraines
Hearing Problems
Hernias
Heart/Circulatory Problems
High/Low Blood Pressure
Infectious Disease
Lymph Node Removal
Motor vehicle accident / trauma
Muscle / Joint Pain
Muscle / Bone Injuries
Numbness or Tingling
Phlebitis
Rash/athletes foot
Seizures
Skin Disorders
Stroke
Varicose Veins
Vision Problems / Contact Lenses
Other
If you selected other in health concerns, please provide details.
MASSAGE INFORMATION
Have you had a professional massage before?
*
Yes
No
How long ago was this treatment?
Reason for seeking Massage?
*
Relaxation Massage
General Wellbeing
Relief from pain / Muscle Tension
Stress Relief
Remedial / Deep Tissue
Headaches
Referral from other Health Practitioner
Other
Thank you!