Client Contact Information Name * Date of Birth * Address *0 / 65 Phone * Email * Referred by/How did you hear about us? Have you ever received professional massage/bodywork before?YesNoOther/Unsure What kind of pressure do you prefer?LightMediumDeepOther/Unsure Current & Past Health Status List any sites of pain, stiffness, or tenderness and explain the cause of each. Are you pregnant or trying to become pregnant?YesNoOther/Unsure Are you currently being treated for a medical condition, injury, surgery, etc?YesNoOther/Unsure Explain Have you had any injuries or surgeries in the past that may influence today’s treatment?YesNoOther/Unsure Explain Check all conditions that apply to your personal health. Explain if applicable.Allergies/AsthmaRashesAthlete’s FootBlood clotsInfectionsWartsBroken/Fractured BonesArthritisHeadachesChronic PainHepatitisThyroid ConditionOsteoporosisHeart ConditionVaricose VeinsBlood ClotsCold/Flu SymptomsTMJ / Jaw PainHead InjuriesSleep DisorderCancer/TumorsDepressionEpilepsy/SeizuresBruisesContact LensesDenturesBone or Joint DiseaseBursitis/TendonitisAuto Immune DiseaseHigh/Low Blood PressureSpasms/CrampsSprains/StrainsThrombosisNumbness/TinglingDiabetesSlipped/Herniated DiscCardiac/Circulatory IssuesOther Other/Comments Consent for Treatment *If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes 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 see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners 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 given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand 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 payment of the scheduled appointment. Client Signature *Typing your name into the signature field will be considered your legal signature Parent/Guardian Signature (for minors)Typing your name into the signature field will be considered your legal signature Date * Send Message Please do not fill in this field.
