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Name:_______________________________Birthdate:________________________ Address: ________________________________City:_________________________ Apt: ___________ State: _______________ Zipcode: ________________ Phone: (H) ____________________________Work:_______________________ When was your last massage? _____________How much water do you drink? Reason for today’s visit:___________________________________________ List any accidents, fractures, and surgeries in the past 5 years:
How often & what type of exercise do you do?_________________________ Describe any current or ongoing musculoskeletal pain or stiffness & current medications:
Are you pregnant? (No) ______ (Yes) ________Due date: ________________ Allergies to any oils, lotions,scents? (No) __________ (Yes) ___________________ If yes, please list: ______________________________________________________ Please check all that apply __Muscle Tightness __Fibromyalgia __Kidney proble __Muscle Cramps __Tendonitis __Liver problems __Wear Hearing Aid __Swollen extremities __Sciatica __Gall Bladder problems __Pregnant __Numbness __Herniated Disc __Stomach problems __PMS/painful periods __Cold Hands __Osteoporosis __Skin Ulcers __Fluid retention __Cold Feet __Varicose Veins __Seizures/convulsions __Depression __Easy Bruising __Hepatitis __Immune deficiency __Dizziness __Herpes __Low Blood Pressure __Scoliosis __Fainting __Skin irritation __High Blood Pressure __Sports Injuries __Loss of Balance __Skin sensitivity __Heart Disease __Chronic Fatigue Syn. __Inner ear problem __Allergies __Diabetes __Osteoarthritis __Night Sweats __Migraines __Cancer __Sleep problems __Asthma __Hypoglycemia __Fatigue __Joint pain __Thyroid __Arthritis __Bladder problem __Initials This information and our sessions are treated with confidentiality. Please give feedback at any time during or after the massage. This communication between you and I during the massage will facilitate a more productive outcome from the session for you. I, the client, understand that the work done during this massage does not constitute medical treatment and that the massage therapist is not a physician. The session is a form of health and wellness maintenance utilizing the techniques of massage and holistic healing, I, the client, take responsibility for alerting the therapist to any conditions that might affect this work. It is recommended that I, the client, see a physician for any ailments I might have. Any suggestions made by the massage therapist are recommendations not prescriptions. My signature below indicates that I understand and agree to the above conditions. Signature: ________________________________________Date:__________________________ Cancellation Policy: Failure to cancel an appointment 24 hours in advance will be subject to a $60 no show fee. |
