Steele's Therapeutic Massage



Health Intake FormSteeles Therapeutic Massage1382 West Pitt StreetP.o. Box 425Jennerstown PA 15547Name_________________________________Date_____________Date of Birth_______________ Gender_______________Address______________________________________ Town/City_______________________State______________________ Zip code___________________Email_______________________________ Phone_________________________________Employer_________________________ Job title__________________________Emergency contact________________________________ Phone___________________________Main complaint: ________________________________________________________________What makes it feel better? _________________________What makes it feel worse? _________________________Is it worse in the morning or at night? ____________________On a scale of 1-10, 10 being worst, how bad is your pain:At this time: ______At the time of injury: ______At its best: ______At its worst: ______How would you describe the pain (ex: burning, aching, stinging, numbness, ect.)___________________________________________________________________________________________What medications do you currently take? ____________________________________________Previous surgeries? _____________________________________________________________Any known allergies? ____________________________________________________________Are you currently pregnant? ______________________________________________________Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: Current Past Muscle or joint pain ______________________________________________________Current Past Numbness or tingling______________________________________________________Current Past High/Low blood pressure __________________________________________________Current Past Stroke or heart attack_____________________________________________________Current Past Epilepsy or seizures _______________________________________________________Current Past Arthritis ________________________________________________________________Current Past Broken bones____________________________________________________________Current Past Diabetes ________________________________________________________________Have you had any injuries, surgeries or any health conditions currently or in the past that may affect today’s Massage? ____________________________________________________________________________________________________________________________________________________________Consent for MassageIf 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 this session given should be construed as such. Because massage/bodywork should not be preformed 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 sexual suggestion, 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. Understanding all of this, I give my consent to receive care.Client signature ________________________________________________________ Date __________Parent/Guardian signature (in case of minor) ________________________________ Date___________ ................
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