2010

NAME: DATE: / /
ADDRESS: Birthday: / /
CITY, STATE, ZIP:
TELEPHONE: Home: Work: Cell:
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EMPLOYER/OCCUPATION:
REFERRED BY:

CONFIDENTIAL PERSONAL HEALTH INFORMATION

Have you ever had a professional massage before? ______How long ago? ______

What type of massage do you prefer? (circle one) Swedish Deep Tissue($12 more) Pain Management Other

Do you have a preference for gentle, moderate or deep muscle work? ______

Are you sensitive or allergic to any skin care products or aromas? ______

Please check areas of your body that you give permission to receive massage.

CIRCLE MAJOR COMPLAINING AREA:

BACK _____LEGS _____BUTTOCKS _____ ARMS _____FEET _____STOMACH _____

CHEST_____NECK _____HEAD_____FACE _____OTHER ______

We do not engage in breast massage in any standard therapies. In Lymphatic Drainage Therapy it is part of the procedure and we must have the written consent of the client.

Please initial here if this is Lymphatic Drainage Therapy._____

Are you under medical treatment or some kind of therapy that would be affected by massage? ______If so, for what condition? ______

Doctor ______Phone ______

Please list any accidents or operations that would be affected by massage in the past 5 years: ______

______

If you have had Lymph node removal or Radiation treatment, a massage could cause edema. (swelling and discomfort)

OVER

HEALTH HISTORY

Do you have, or have you ever had, any of the following conditions:

BACK _____SPEECH _____CARDIOVASCULAR _____BLOOD CLOTS _____

NECK _____STRESS _____CIRCULATORY _____SHOULDERS _____

PMS _____SCIATIC _____DIGESTIVE _____DIABETES _____

TMJ _____CANCER _____RESPIRATORY _____WHIPLASH _____

SINUS _____HEARING _____HEADACHES _____ARTHRITIS _____

ALLERGIES _____SEIZURES _____DEPRESSION _____HEAD INJURIES _____

TUMORS _____BLOOD PRESSURE _____ (HIGH/LOW)BROKEN BONES _____

ARE YOU PREGNANT? _____VARICOSE VEINS _____HEART______

SKIN DISORDER _____

VISION _____ (DO YOU WEAR CONTACTS) DO YOU WEAR A HEARING AID? ______

DRAPING: Keeping the unclothed body properly draped at all times is necessary for your warmth and sense of ease; as well as a mark of our professionalism.

RELEASE & CONSENT:

All the information is accurate and I have stated all medical conditions that I am aware of and I agree to inform the massage therapist about any changes in my health status prior to receiving massage in the future.

I understand it is my choice to receive massage therapy. I realize that the treatment is being given for the well being of my body and mind. This includes stress reduction, relief from muscular tension, spasm and pain, and for increasing circulation or energy flow. Certain massage manipulations may result in bruising or discoloration of the skin. I agree to immediately inform the massage therapist of any pain, unusual sensitivity or feelings of discomfort that I may experience during my massage. The massage may be terminated at that time.

I understand that the massage therapist does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical treatment and is recommended that I see my doctor for that service.

Signature ______Date ______

Signature of Therapist ______Date ______

If under 18, a parent or guardian must sign this form.

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