Client General Information
Name(PRINT):______Date of Birth:______
Physical Address: ______City:______State:______Zip Code:______
Mailing Address:______
E-Mail:______
Telephone: Home:______Cell:______Work:______
Emergency Contact: Name:______Relationship:______
Emergency Contact Telephone #’s: Home:______Cell:______Work:______
Primary Physician: Name:______Phone#:______
Physician’s Address:______
What is your occupation? ______
What is your reason for seeking massage services or bodywork at this time?______
What is the outcome or expectations that you are seeking?______
Have you experienced a professional massage or bodywork session before? YES NO How Recent?______
Describe your experience:______
Who was your therapist?______
How did you find out about Kathryn Pasteka, LMT, DBA: Fort Bend Massage Therapeutics?______
Client Signature:______Date:______
Therapist Signature:______Date:______
Client Medical Questionnaire
Please circle yes or no to the following questions. Write details on the back of this page when answering yes.
Yes / No / Do you have any contagious disease?Yes / No / Do you have ANY allergies to food, medications, seasonal allergens?
Yes / No / Are you wearing contact lenses? Yes No Are you wearing dentures or partials?
Yes / No / Are you pregnant? If yes, what trimester?______Due date?______Is this your 1st pregnancy? ______Prior miscarriages?______How many?_____
Yes / No / Do you have diabetes? If yes, are your sugar levels under control by:
Circle applicable: Diet * Medication * Insulin Injections * Insulin Pump
Please give detail of any diabetic complications or uncontrolled blood sugar level
Yes / No / Do you suffer from epilepsy or seizures? Please explain on back >
Yes / No / Do you have high or low blood pressure? Circle: High BP Low BP
Yes / No / Do you suffer from stress? Circle: Traumatic event? Everyday issues?
Yes / No / Do you suffer from headaches? Circle applicable: Where?All over, left side, right side, eyes, backof neck? Are they: sharp, dull, throbbing? Frequency: daily, weekly, every couple months, etc. ? Duration: minutes, hours, days?
Yes / No / Do you have arthritis? If yes, circle applicable choice: Doctor DX osteoarthritis *
Doctor DX rheumatoid * Other DX form of arthritis
Yes / No / Do you suffer from joint swelling?
Yes / No / Do you have osteoporosis?
If yes, have you suffered broken or cracked bones from the osteoporosis? Yes * No >
Yes / No / Do you have varicose veins?
Yes / No / Do you bruise easily?
Yes / No / Do you have numbness or stabbing pains anywhere? Explain >
Yes / No / Do you have tension or soreness in a specific area? Please specify:______
Yes / No / Do you have cardiac or circulatory problems? Describe>
Yes / No / Are you sensitive to touch or pressure in any area?
Yes / No / Do you suffer from back pain?
Yes / No / Have you had any surgeries? (a separate form has been included to list surgeries)
Yes / No / Have you been in any accident or suffered any injuries in the past two years?
Yes / No / Have you been in any accident or suffered any injuries longer than two years ago
Yes / No / IF you answered yes regarding accidents/injuries are these significant to your seeking massage therapy? Explain >
Yes / No / Do you have any other medical condition that I should be aware of?
Yes / No / Are you taking any medications or supplements? (see separate form)
Client Printed Name:______
Client Signature:______Date:______
Therapist Signature:______Date:______
Client Disclosure:
Certain medical conditions or symptoms may be contraindicated and may require that your primary care physician provide consent or referral prior to massage or bodywork services being provided. I understand that massage/bodywork is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my massage/bodywork session(s) I immediately will inform the therapist sothat pressure and/or technique may be adjusted to my level of comfort. I further understand that massage/bodywork should NOT be construed as a substitute for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of or have question regarding such. I understand that massage/bodyworktherapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session(s) should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my medical conditions, and answered all questions on each intake page and/or form honestly. I agree to keep the therapist updated, in writing, as to any changes in my medical and medication profile and understand thatthere shall be NO liability on the therapists part should I neglect to do so. It is understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment.
Client Name printed: ______
Client Signature:______Date:______
Therapist Signature:______Date:______
Client Consultation & Policy Guidelines
Client Name: (PRINT) ______
Your Physical Address: ______
Type of Massage Therapy:
Massage techniques may include the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for the purpose of body massage and includes effleurage (stroking), petrissage (kneading), tapotement (percussion) , compression, vibration, friction, nerve strokes, and Swedish Gymnastics, “body massage”, or any derivation of those terms are synonyms for “massage Therapy”.
Your Licensed Massage Therapist, Kathryn Pasteka, has received additional training in various modalities and advanced techniques that may enhance your session. This knowledge will be used to individualize your session(s) for the benefit of helping you achieve your therapeutic or relaxation goals. As with any other health care activity or body maintenance, no guarantee is being made or implied as to the individual results you may achieve.
Body Areas:
Relaxation or therapeutically focused massage may or may not include areas of the body, such as feet, legs, buttocks, back, neck, head, face, chest muscles, shoulders, arms, hands, and the stomach.
The therapist has reviewed and discussed with me, the Client Medical Information form that I have completed. I understand what areas that may be or will be massaged and have communicated to the therapist any areas that I do not want touched. I understand that it is my responsibility to advise the therapist of any areas I do not want touched on any subsequent divests as this may change for me from session to session.
In the State of Texas, breast massage on a female client is a legal therapeutic massage service; however, no such service will be rendered without a separate written consent form. I understand that breast massage DOES NOT include touching of the nipple or areola should I choose to request breast massage.
I understand that massage in this office doesnot include any sexual behavior or gratification and none will be tolerated. There will be NO touching of the genitals by client or therapist. Any illicit or sexually suggestive remarks or advances made by me, the client, will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment.
Draping:
I understand that the therapist will use draping during the massage session(s) unless otherwise agreed to by both myself and the therapist. I understand that if I am a male client that draping is required by this therapist unless as a male client I am wearing outer shorts.
Cessation of Session(s):
I understand that as the client, should I feel uncomfortable receiving massage at any time during the session, for any reason, I have the right to ask that the session end and the therapist will immediately honor that request. I understand that termination of session(s) on my part does not exclude my responsibility for the amount due for the full session I have booked.
Cancellations:
I, the client, agree, as a courtesy, that I shall give notice as soon as it is discovered that I must cancel or reschedule an appointment. I understand that a minimum 24 hour notice is required for canceled or rescheduled appointments and that should I fail to give the full 24 hour notice that I will be liable for the payment of the session unattended. I further understand that repeated cancelations or “no shows” shall deem me as an unreliable or disinterested client and that no further appointments will be made available without payment in advance and I risk the possibility of being refused any appointments in the future. At the sole discretion of the therapist, special needs or emergency circumstances may be taken into consideration for possible waiver of payment on an individual client and a per session basis.
Arrival Time:
After this first massage session, your therapist hopes that you will bepleased with your results and that you will offer the opportunity to serve you with future massage sessions. However, in efforts to keep all my clients comfortable with their privacy and in maintaining a “no waiting time” office, please adhere to the following for future appointments: Arrive on time or not more than 5 minutes early. Call if you are running morethan 5 minutes late. If you are running late, it will be at the sole discretion of the therapist whether or not to give you your full scheduled time; but…..due to the nature of the “by appointment only” service, your session may be cut short by the amount of time for which you were late. Late arrivals will be charged for the full session booked regardless of the actual session time being rendered.
Payment:
Payment can be made check or cash. A copy of your driver’s license will be required to be on file for writing checks. You will be charged full fees allowed by law for any returned check. If you choose not to pick up a returned check and pay allassociated fees, you will be prosecuted in a court of law. Special arrangements can be made via PayPal for credit card payment needs. There will be a $5.00 convenience fee added to the normal session charge for each session paid through PayPal. The use of PayPal must be on a “pre-payment” basis and not “post-service payment”.
General Comfort:
It is the therapist intent to offer to you quality massage in an atmosphere as comfortable as possible. This is your massage session, please be sure to let your therapist know if you are uncomfortable in anyway. Is the room temperature too cold or too hot? Would you like a blanket? Would you like the table warmer temperature changed? Is the music too loud or not loud enough? Is there something about the music that is unsettling to you? If so, please ask for the music to be changed. Are you comfortable with your neck position on the table? The headrest is adjustable, just ask. Need a pillow? Etc, etc.
Jewelry on certain areas of the body may hinder the application of effective massage techniques from being used, such as wearing a necklace or large earrings when you are requesting neck massage, or wearing rings when your hands need massage. Please remove related jewelry so that your therapist may serve you better.
If your session (male or female) includes Swedish Gymnastics, wearing of stretchable shorts/sports bra or underclothing is recommended for both your clothing comfort and modesty comfort. Draping may be used but clothing is suggested. The definition of Swedish Gymnastics is defined as “passive and active joint movements, nonspecific stretches, passive and active exercise, or any combination of these”.
Client Signature:______Date:______
Therapist Signature:______Date:______