CONFIDENTIAL PERSONAL HEALTH INFORMATION
2010
|NAME: DATE: / / |
|ADDRESS: Birthday: / / |
|CITY, STATE, ZIP: |
|TELEPHONE: Home: Work: Cell: |
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|EMPLOYER/OCCUPATION: |
|REFERRED BY: |
CONFIDENTIAL PERSONAL HEALTH INFORMATION
Have you ever had a professional massage before? ________How long ago? _________________
What type of massage do you prefer? (circle one) Swedish Deep Tissue($12 more) Pain Management Other
Do you have a preference for gentle, moderate or deep muscle work? _______________________
Are you sensitive or allergic to any skin care products or aromas? __________________________
Please check areas of your body that you give permission to receive massage.
CIRCLE MAJOR COMPLAINING AREA:
BACK _____ LEGS _____ BUTTOCKS _____ ARMS _____ FEET _____ STOMACH _____
CHEST_____ NECK _____ HEAD_____ FACE _____ OTHER _________________
We do not engage in breast massage in any standard therapies. In Lymphatic Drainage Therapy it is part of the procedure and we must have the written consent of the client.
Please initial here if this is Lymphatic Drainage Therapy._____
Are you under medical treatment or some kind of therapy that would be affected by massage? ______________________________ If so, for what condition? ______________________ __________________________________________________________________________
Doctor _________________________ Phone ________________
Please list any accidents or operations that would be affected by massage in the past 5 years: ___________________________________
______________________________________________________________________________
If you have had Lymph node removal or Radiation treatment, a massage could cause edema. (swelling and discomfort)
OVER(
HEALTH HISTORY
Do you have, or have you ever had, any of the following conditions:
BACK _____ SPEECH _____ CARDIOVASCULAR _____ BLOOD CLOTS _____
NECK _____ STRESS _____ CIRCULATORY _____ SHOULDERS _____
PMS _____ SCIATIC _____ DIGESTIVE _____ DIABETES _____
TMJ _____ CANCER _____ RESPIRATORY _____ WHIPLASH _____
SINUS _____ HEARING _____ HEADACHES _____ ARTHRITIS _____
ALLERGIES _____ SEIZURES _____ DEPRESSION _____ HEAD INJURIES _____
TUMORS _____ BLOOD PRESSURE _____ (HIGH/LOW) BROKEN BONES _____
ARE YOU PREGNANT? _____ VARICOSE VEINS _____ HEART______
SKIN DISORDER _____
VISION _____ (DO YOU WEAR CONTACTS) DO YOU WEAR A HEARING AID? ______
DRAPING: Keeping the unclothed body properly draped at all times is necessary for your warmth and sense of ease; as well as a mark of our professionalism.
RELEASE & CONSENT:
All the information is accurate and I have stated all medical conditions that I am aware of and I agree to inform the massage therapist about any changes in my health status prior to receiving massage in the future.
I understand it is my choice to receive massage therapy. I realize that the treatment is being given for the well being of my body and mind. This includes stress reduction, relief from muscular tension, spasm and pain, and for increasing circulation or energy flow. Certain massage manipulations may result in bruising or discoloration of the skin. I agree to immediately inform the massage therapist of any pain, unusual sensitivity or feelings of discomfort that I may experience during my massage. The massage may be terminated at that time.
I understand that the massage therapist does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical treatment and is recommended that I see my doctor for that service.
Signature _________________________________________ Date ____________
Signature of Therapist _______________________________ Date ____________
If under 18, a parent or guardian must sign this form.
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