Client Contact InformationName *Date of Birth *Gender *Address *0 / 280Phone *Email *Referred byEmergency ContactPhonePhysician/Health-care Provider NamePhoneMassage PreferencesHave you ever received professional massage/bodywork before?YesNoOther/UnsureHow recently?What types of massage/bodywork do you prefer?What kind of pressure do you prefer?LightMediumFirmOther/UnsureWhat are your goals/expected outcomes for receiving massage/bodywork?Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?YesNoOther/UnsureDo you have a physician referral/prescription?YesNoOther/UnsureCurrent Health StatusHow do you feel today?List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.)Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?YesNoOther/UnsureExplainList any medications or supplements you currently takeAre you wearing contacts?YesNoOther/UnsureAre you wearing dentures?YesNoOther/UnsureAre you wearing a hairpiece?YesNoOther/UnsureAre you pregnant?YesNoOther/UnsureDo you currently have any of the following health conditions? Please answer honestly, as massage may not be indicated for some of these conditions. (if you are unsure, please ask)Blood clotsInfectionsCongestive heart failureContagious diseasesPitted edemaOther/CommentsHealth HistoryHave you had any injuries or surgeries in the past that may influence today’s treatment?YesNoOther/UnsureExplainPlease indicate conditions that you have or have had in the past. Explain in detail, including treatment received.Muscle or joint painCurrentPastNeverExplainMuscle or joint stiffnessCurrentPastNeverExplainNumbness or tinglingCurrentPastNeverExplainSwellingCurrentPastNeverExplainBruise easilyCurrentPastNeverExplainSensitive to touch/pressureCurrentPastNeverExplainHigh/Low blood pressureCurrentPastNeverExplainStroke, heart attackCurrentPastNeverExplainVaricose veinsCurrentPastNeverExplainShortness of breath, asthmaCurrentPastNeverExplainCancerCurrentPastNeverExplainNeurological (e.g. MS, Parkinson’s, chronic pain)CurrentPastNeverExplainEpilepsy, seizuresCurrentPastNeverExplainHeadaches, MigrainesCurrentPastNeverExplainDizziness, ringing in the earsCurrentPastNeverExplainDigestive conditions (e.g. Crohn’s, IBS)CurrentPastNeverExplainGas, bloating, constipationCurrentPastNeverExplainKidney disease, infectionCurrentPastNeverExplainArthritis (rheumatoid, osteoarthritis)CurrentPastNeverExplainOsteoporosis, degenerative spine/diskCurrentPastNeverExplainScoliosisCurrentPastNeverExplainBroken bonesCurrentPastNeverExplainAllergiesCurrentPastNeverExplainDiabetesCurrentPastNeverExplainEndocrine/thyroid conditionsCurrentPastNeverExplainDepression, anxietyCurrentPastNeverExplainMemory Loss, confusion, easily overwhelmedCurrentPastNeverExplainOther/Additional Comments:COVID-19 InformationHave you had a fever of 100°F or above in the last 24 hours? *YesNoOther/UnsureDo you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? *YesNoOther/UnsureHave you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? *YesNoOther/UnsureExplain *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.Additional Consent for Treatment during COVID-19 *I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from this practitioner.Understanding all of this, I give my consent to receive care. *I agree.Client Signature *Typing your name into the signature field will be considered your legal signatureParent or Guardian Signature (in case of a minor)Typing your name into the signature field will be considered your legal signatureDate *Send MessagePlease do not fill in this field.
