KATHLEEN SHADRICK

Massage Therapist

Name______

Address______City______State______Zip______

Phone______Profession/Occupation______

Age_____ Birthdate______Email:______

I, the undersigned person, do agree and understand that Kathleen Shadrick is not a Medical Physician, Osteopathic Physician, Chiropractor, Registered Nurse, Licensed Practical Nurse, Licensed Physical Therapist or Physio-Therapist. I understand and agree that Kathleen Shadrick does not diagnose, prescribe or claim to treat for any condition or ailment. I understand and agree that she only claim to be Massage Therapist, and she provide the services of Massage Therapy and Flexibility Therapy only. I affirm that I have come to this place to avail myself of the service of Massage Therapy and have not nor will not ask her to do anything that is illegal in the state of Indiana, nor anything that is against her personal or professional moral code.
I, the undersigned person, affirm that all of the information given in this document and the following questions and answers are true to the best of my knowledge.
Signed______Date______Witness______

Briefly describe the reason you are seeking massage therapy at this time.______
______

  1. Have you had any injuries to your spine or neck? (Yes) (No)

If yes, please explain______
______

  1. Have you had any surgeries in the past year? (Yes) (No)

If yes, please explain______

______

  1. Have you had, or do you have, any blood clots or tumors that you are aware of? (Yes) (No)

If yes, please explain______
______

  1. Do you have a medical condition that I should be aware of before giving you therapy? (Yes) (No) If yes, please explain______
    ______
  2. Are you now taking any prescription drugs? (Yes) (No)

If so, please list the names______

______

  1. Have you had any changes in your physical health in the last few months, or since your last visit?

(Yes) (No) Please explain______

______

Do you wear contacts (Yes) (No) Thank you, Kathleen

Please mark areas of pain or symptom