Name
Date
Referred By
Address
City
Postcode
Phone 1
Phone 2
E-mail
Date of Birth
Occupation/Employer
Primary Care Provider
Phone
May we consult with primary care provider? Please initial if yes:YesNo
Emergency contact
Have you ever received a professional massage?YesNo
What results do you want from your sessions?
Prioritize areas of your body that you prefer to be massaged?
Please check any areas of your body where you prefer not to receive massage:headfaceneckarmschestabdomenbackbuttockslegsfeetother
Are you currently seeing a health care practitioner? YesNo
Are you currently seeing a Counselor, Psychotherapist, or a Support Group? YesNo
If yes, please explain
List Stress Reduction and Exercise Activities. Please include frequency:
Current Medications, Herbals & Supplements and reason for use. Please include OTCs such as aspirin, ibuprofen, Claritin, etc.
Surgeries
Accidents
Bone or Joint DiseaseTendonitis/BursitisBroken/Fractured BonesArthritis/GoutJaw pain/TMDLupusSprains/StrainsLow Back, Hip, Leg PainNeck, Shoulder, Arm PainHeadaches, Head InjuriesSpasms/CrampsOther
Heart ConditionVaricose Veins/PhlebitisBlood ClotsHigh/Low Blood PressureLymphedemaThrombus/EmbolismOther
Breathing Difficulty/AsthmaEmphysemaAllergies; SpecifySinus ProblemsOther
Herpes/ShinglesNumbness/TinglingPinched NerveOther
Pregnant; TrimesterOvarian/Menstrual ProblemsProstatePMSOther
Allergies; SpecifyRashesAthletes FootHerpes/Cold SoresWartsOther
ConstipationGas/BloatingDiverticulitisIrritable Bowel SyndromeUlcersOther
Cancer/TumorsDiabetesChronic FatigueChronic PainEating DisordersSleep DisordersBladder/Kidney ailmentDrug/Alcohol AddictionCaffeine/Tobacco AddictionMigraines/HeadachesAnxiety/Stress SyndromeDepressionContact Lenses
It is my choice to receive massage therapy and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. I understand that a massage therapist cannot diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my wellbeing is compromised. I acknowledge that massage is not a substitute for medical examination or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have.
I understand that massage therapy is a therapeutic health aide and is non-sexual.
Patient Signature
Date:
Therapist Signature
Open 7 Days, 10am to 8pm