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Client Health Consultation
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Personal Data

 
 
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Massage History/Treatment Information

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headfaceneckarmschestabdomenbackbuttockslegsfeetother

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Previous History (Include year & treatment received)


Health History

Musculoskeletal

Bone or Joint DiseaseTendonitis/BursitisBroken/Fractured BonesArthritis/GoutJaw pain/TMDLupusSprains/StrainsLow Back, Hip, Leg PainNeck, Shoulder, Arm PainHeadaches, Head InjuriesSpasms/CrampsOther

Musculoskeletal

Heart ConditionVaricose Veins/PhlebitisBlood ClotsHigh/Low Blood PressureLymphedemaThrombus/EmbolismOther

Respiratory

Breathing Difficulty/AsthmaEmphysemaAllergies; SpecifySinus ProblemsOther

Nervous

Herpes/ShinglesNumbness/TinglingPinched NerveOther


Reproductive

Pregnant; TrimesterOvarian/Menstrual ProblemsProstatePMSOther

Skin

Allergies; SpecifyRashesAthletes FootHerpes/Cold SoresWartsOther

Digestive

ConstipationGas/BloatingDiverticulitisIrritable Bowel SyndromeUlcersOther

Other

Cancer/TumorsDiabetesChronic FatigueChronic PainEating DisordersSleep DisordersBladder/Kidney ailmentDrug/Alcohol AddictionCaffeine/Tobacco AddictionMigraines/HeadachesAnxiety/Stress SyndromeDepressionContact Lenses


Consent & Contract for Care

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.