Rentontechnicalcollege Massage Therapy Practitioner Course

RentonTechnicalCollege Massage Therapy Practitioner Course

Client Name ______Date ______

Have you had a professional seated massage? □ yes □ no

Are you currently experiencing any of the following?

Pain, numbness, tingling, dizziness, bruise easily, limitations in activities:

□ yes □ no if any list: ______

______

Infections Ex: Flu, Fever, common cold, bladder infection, etc.

□ yes □ no if any list: ______

Infectious skin disease? Ex: Warts, Scabies

□ yes □ no if any list: ____________

Are you pregnant, trying to get pregnant, or is there any possibility of being pregnant? □ yes □ no □ N/A

Have you experienced any of the following?

Sensitive skin, Contact Dermatitis, Allergies □ yes □ no

if yes explain: ______

Circulatory/Heart ConditionsEx: Coronary artery disease, Thrombosis, etc.

□ yes □ no if any list: ______

High/low blood pressure □ yes □ no

if yes, is it controlled by medication? ______

Cancer □ yes □ no if yes, onset/type/treatment/in remission?

______

Other: ex: Spinal problems, auto accident(s), surgeries: □ yes □ no

if any list: ______

______

Current medications (and what for): ______

______

I understand that I am receiving a massage from a Student Massage Practitioner (SMP), and that the SMP does not perform spinal manipulation, diagnose, nor prescribe. I have read, understood and accurately completed this health intake and have discussed my health condition with the SMP. I understand that I am receiving massage at my own risk. I understand that it is my responsibilityto let the student know any time during the massage if I would like them to do anything differently, including modifying the pressure.

Client Signature ______Date ______

RentonTechnicalCollege Massage Therapy Practitioner Course

Client Name ______Date ______

Have you had a professional seated massage? □ yes □ no

Are you currently experiencing any of the following?

Pain, numbness, tingling, dizziness, bruise easily, limitations in activities:

□ yes □ no if any list: ______

______

Infections Ex: Flu, Fever, common cold, bladder infection, etc.

□ yes □ no if any list: ______

Infectious skin disease? Ex: Warts, Scabies

□ yes □ no if any list: ____________

Are you pregnant, trying to get pregnant, or is there any possibility of being pregnant? □ yes □ no □ N/A

Have you experienced any of the following?

Sensitive skin, Contact Dermatitis, Allergies □ yes □ no

if yes explain: ______

Circulatory/Heart Conditions Ex: Coronary artery disease, Thrombosis, etc.

□ yes □ no if any list: ______

High/low blood pressure □ yes □ no

if yes, is it controlled by medication? ______

Cancer □ yes □ no if yes, onset/type/treatment/in remission?

______

Other: ex: Spinal problems, auto accident(s), surgeries: □ yes □ no

if any list: ______

______

Current medications (and what for): ______

______

I understand that I am receiving a massage from a Student Massage Practitioner (SMP), and that the SMP does not perform spinal manipulation, diagnose, nor prescribe. I have read, understood and accurately completed this health intake and have discussed my health condition with the SMP. I understand that I am receiving massage at my own risk. I understand that it is my responsibilityto let the student know any time during the massage if I would like them to do anything differently, including modifying the pressure.

Client Signature ______Date ______

SMP ______Date ______