Boonville.massagetherapy.com



BOONVILLE MASSAGE THERAPY, LLC _____________________________

_____________________________

PERSONAL INFORMATION

First Name _______________________________ Last Name ______________________________ M.I. _____________

DOB__________________________ Gender __________________ Occupation ________________________________

Address __________________________________________________________________________________________

City ___________________________________________ State _______________ Zip Code ______________________

Cell Phone # ____________________________________ Home Phone # ______________________________________

Email Address _____________________________________________________________________________________

Please note: Cell phone number and email address are used for appointment reminders/receipts

Emergency Contact ____________________________ Phone # __________________ Relationship ________________

Referred by (referral, Facebook, Google) ________________________________________________________________

ISSUES TO ADDRESS

Cause of Injury or Concern: ___________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

How long since first noticed? __________________________________________________________________________

Describe your treatment goals: _________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Past treatments: ____________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Please list serious surgeries or illnesses __________________________________________________________________

__________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

FEMALES ONLY: Total number of pregnancies _________ Total number of children ___________

MASSAGE INFORMATION

Have you ever received a professional massage before? Yes No Date of last massage __________________

Pressure Preference on a 1-10 scale (0 = light, 10 = firm) 0 1 2 3 4 5 6 7 8 9 10

List areas of your body you want me to avoid (feet, face, etc): _______________________________________________

Room Temperature Preference: WARM COOL OTHER: _________________________________________

EXISTING CONDITIONS INFORMATION

Respiratory

← Asthma

← Bronchitis

← Chronic Cough

← Emphysema

← Shortness of Breath

Cardiovascular

← Blood Clots

← Cardiovascular Accident

← Cerebral-vascular Accident

← Cold Feet

← Cold Hands

← Congestive Heart Failure

← Heart Attack

← Heart Disease

← High Blood Pressure

← Low Blood Pressure

← Lymphedema

← Myocardial Infarction

← Pacemaker

← Phlebitis

← Stroke

← Thrombosis / Embolism

← Varicose Veins

Skin

← Bruise Easily

← Hypersensitive Reaction

← Melanoma

← Skin Conditions

← Skin Irritations

Head and Neck

← Ear Problems

← Headaches

← Hearing Loss

← Jaw Pain (TMJD)

← Migraines

← Sinus Problems

← Vision Loss

← Vision Problems

Infectious Conditions

← Athlete’s Foot

← Hepatitis

← Herpes

← HIV

← Respiratory Conditions

← Skin Conditions

Women

← Gynecological Conditions

← Pregnancy

Soft Tissue / Joint Dysfunction

← Ankle (Left)

← Ankle (Right)

← Arm (Left)

← Arm (Right)

← Foot (Left)

← Foot (Right)

← Hand (Left)

← Hand (Right

← Hip (Left)

← Hip (Right)

← Knee (Left)

← Knee (Right)

← Leg (Left)

← Leg (Right)

← Lower Back (Left)

← Lower Back (Right)

← Mid Back (Left)

← Mid Back (Right)

← Neck (Left)

← Neck (Right)

← Shoulder (Left)

← Shoulder (Right)

← Upper Back (Left)

← Upper Back (Right)

Family History

← Cardiovascular Conditions

← Respiratory Conditions

Miscellaneous

← Allergies

← Anaphylaxis

← Artificial Joints / Special Equipment

← Arthritis

← Cancer

← Crohn’s Disease

← Diabetes

← Digestive Conditions

← Dizziness

← Epilepsy

← Fibromyalgia

← Gout

← Hemophilia

← Insomnia

← Loss of Sensation

← Lupus

← Mental Illness

← Osteo Arthritis

← Osteoporosis

← Other Diagnosed Disease

← Other Medical Condition

← Rheumatoid Arthritis

← Shingles

← Stress

← Surgical Pins or Wire

Neurological

← Burning

← Cerebral Palsy

← Herniated Disc

← Multiple Sclerosis

← Numbness

← Parkinson’s

← Stabbing Pain

← Tingling

Please list any medications, drugs, or supplements: ________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Allergies and other conditions your provider should be aware of: _____________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

OFFICE POLICIES

Cancellations

If you cannot keep your scheduled appointment, please call as soon as possible. If you cancel without proper notice (at least six hours) or make no effort to contact your therapist at all (no show), you will be asked to prepay for all future appointments.

INITIAL: ____________

Tardiness

All sessions will start on time, with or without you. Depending upon how late you arrive, your therapist will determine if there is enough time remaining to start a treatment. Regardless of the length of treatment actually given, you will be responsible for the “full” session. Out of respect and consideration to your therapist and other customers, please plan accordingly and be on time.

INITIAL: ____________

Sickness / Illness

Please do not schedule or keep an appointment if you are not feeling well. It is very inconsiderate to knowingly expose your therapist and other clients to any illness you may be experiencing. Massage during illness may exacerbate your symptoms and make you feel worse. Massage will not be performed on clients who are ill, and the office cancellation policy will be implemented.

INITIAL: ____________

Inappropriate Behavior

Any illicit or sexually suggestive remarks or advances will not be tolerated and will result in immediate termination of the session. You will be charged in full for the appointment. The incident will be reported to the local police department.

INITIAL: ____________

Consent for Treatment

• If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

• I understand that massage 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 therapists 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 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

INITIAL: ____________

Understanding and agreeing to all of the above statements, I give my consent to receive care.

Client Signature ___________________________________________________________ Date: __________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download