Massage Therapy – Medical History



Massage Therapy – Medical History

Personal Information:

Name: ____________________________ Date: _________________

Email: ____________________________ Date of Birth(D/M/Y): ___/____/_____

Address: ________________________________________________________

________________________________________________________________

Occupation: _____________________________________

Phone: (daytime) ____________________ _____ Male

(evening) ____________________ _____ Female

Physicians Name: _________________________

Physicians Address: _______________________

Telephone: ______________________________

Emergency Contact: _________________________ Phone: ________________

Current Health Status:

Primary Complaint: _________________________________________________

_________________________________________________________________

Are you currently taking any medications? Yes No

_______________________________________________________

Do you have any allergies to oils, lotions or ointments? Yes No

If yes, please explain ______________________________________

Do you perform any repetitive movements in your work, sports or hobby? Yes No

If yes, please explain _______________________________________

Please check all that apply to you.

❑ Exercise Regularly (If yes, how many times per week? _______________)

❑ Smoking

❑ Alcohol & Drugs

❑ Other Treatments: Chiropractic

❑ Other Treatments: Osteopathic

❑ Other Treatments: Physiotherapy

❑ Other Treatments: _________________

Please identify the areas you would like focused on during your treatment:

Are you currently under any medical supervision? Yes No

If yes, please explain __________________________________________________

Please check any condition listed below that applies to you:

|CVA (Stroke) |Multiple Sclerosis |

|Hypertension |Loss of Sensation |

|Low Blood Pressure |Pregnancy |

|CCHF |Arthritis |

|Diabetes |Local Skin Irritation (e.g. Psoriasis) |

|Dizziness |Digestive Condition (e.g. Irritable Bowel, Colitis) |

|Chest Pain |Chronic Abdominal Discomfort |

|Respiratory Condition: (e.g. Asthma Emphysema) |Osteoporosis |

|Fibromyalgia |Hernia |

|Bronchitis |HIV / AIDS |

|Difficulty Breathing |Hepatitis |

|Tuberculosis |Varicose Veins |

|Epilepsy |Cancer |

|Other: ________________ |Other: __________________ |

Please explain any condition that you marked above: _____________________________

________________________________________________________________________

________________________________________________________________________

List any past surgeries or injuries.

________________________________________________________________________

Date: ______________________ Treatment Received: _________________________

________________________________________________________________________

Date: ______________________ Treatment Received: _________________________

________________________________________________________________________

Date: ______________________ Treatment Received: _________________________

________________________________________________________________________

Date: ______________________ Treatment Received: _________________________

I certify that the information given on this form is true and accurately reflects my past and present health status and I provide consent for further treatment.

Signature: ________________________ Date: ____________________________

Cancellation Policy

Due to the increasing demand for Massage Therapy and a number of missed appointments, we are implementing a cancellation policy effective AUGUST 11, 2008

Cancellation Policy

Our time together is important!

24 hour advance notice is required to cancel or change the duration of an appointment. If unable to give advance notice the full treatment fee will be applied.

Missed Appointments

Appointments missed without advance notice may be subject to full charge.

Late Arrival

The remainder of the appointment will be honored however you will be responsible for the session in full.

Please understand that we cannot bill insurance providers for missed appointments and cancellations!

Signature: Date:

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

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

Google Online Preview   Download