Therapy assessment form Step 1 of 4
HPW Therapy Clinics, by House of Peace and Wellness

Quick health check

So your therapist knows what to be careful about before you arrive — not after.

Nothing filled in 12 questions, about two minutes. Your therapist reads them before you walk in, so nothing has to be explained on the table.
1
About you Your age decides the rate for some therapies, and we book male clients with male therapists and female clients with female therapists. Both are asked once and kept on your booking.
In years.
2
What brings you in? Pick the closest. Your therapist will ask more when you arrive. Your answer from
3
Where is it? Choose as many as apply. Asked fresh every time
4
How long has it been going on? Your answer from
5
How bad is it right now? Ten is the worst pain you can imagine. There is no right answer and nothing is refused because of it. Asked fresh every time
1–4 mild 5–8 moderate 9–10 severe
6
Do any of these apply to you? · optional Some of these change the pressure, the heat or the length of a session. Your answer from
7
Are you under medical treatment at the moment? Including anything prescribed that you take regularly. Your answer from
8
Any surgery, fracture or injury in the last year? Your answer from
9
Are you pregnant? It changes which positions and which therapies are safe. Your answer from
10
Have you had massage therapy before? Your answer from
11
Did a previous session ever leave you uncomfortable? Only asked so it does not happen again. Your answer from
12
Will you have eaten within an hour of your session? Steam, ice bath and abdominal work are better on an empty stomach. We will move the order of things around rather than cancel. Asked fresh every time
13
Anything else your therapist should know? · optional Pressure you like, areas to avoid, or anything you would rather say now than on the table. Your answer from
Recorded against consent wording v1.0, with the date and time you agreed.
One thing left
Before proceeding, please read and follow the session guidelines and instructions.
Therapy assessment form