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Client Health Consultation
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    Personal Data

     
     
    YesNo

    Massage History/Treatment Information

    YesNo
    headfaceneckarmschestabdomenbackbuttockslegsfeetother

    YesNo
    YesNo


    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.