HEALTH HISTORY INTAKE for MASSGE THERAPY



HEALTH HISTORY INTAKE for MFR Treatment

Name_______________________________________________ Date of initial visit___________

Address___________________________________________________ Phone_______________

Occupation____________________________________________ Date of Birth______________

Name of Physician_______________________________________ Phone__________________

Other healthcare provider________________________________ Referred by________________

1. Have you had massage therapy before? Yes __ No

2. For women: Are you pregnant? Yes No If yes, how many months? _______

3. Do you have any difficulty lying on your back, or side? Yes No Both

4. Do have allergic reactions to oils, lotions, ointments, liniments, or other substances put on your skin? Yes No If yes please explain_______________________________________

5. Do you wear contact lenses ( ) dentures ( ) a hearing aid ( )?

6. Do you sit for long hours at a workstation, computer, or driving? Yes No

7. Do you perform any repetitive movement in your work, sports, or hobby? Yes No

8. Do you experience stress in your work, family, or other aspects of your life? Yes No

How would you describe your stress level? Low Medium High Very High

If high, how do you think stress has affected your health? muscle tension ( ) anxiety ( ) insomnia ( ) irritability ( ) other ( )

9. Is there a particular area of the body where you are experiencing tension, stiffness, or other discomfort? Yes N If yes, please identify_________________________________________

In order to plan a massage session that is safe and effective, we need some general information about your medical history.

10. Are you currently under medical supervision? Yes No

If yes, please explain__________________________________________________________________

11. Are you currently taking any medication? Including Aspirin, Ibuprofen, Herbs. Yes No

If yes please list______________________________________________________________________

12. Please check any condition listed below that applies to you: “X” for all conditions that apply now, “P” for past conditions, and “F” for family history of illness NA not applicable

_____ Skin condition (e.g. acne, rash, skin cancer, allergy, easy bruising, contagious condition)

_____ Allergies

_____ Birth Control

_____ Diabetes

_____ Recent accident, injury, or surgery (e.g. whiplash, sprain, broken bone, deep bruise)

_____ Muscular problems (e.g. tension, cramping, chronic soreness)

____ Joint problems (e.g. osteoarthritis, rheumatoid arthritis, gout, hypermobile joints, recent dislocation)

____ Lymphatic condition (e.g. swollen glands, nodes removed, lymphoma, lymphedema)

_____ Circulatory or blood conditions (e.g. atherosclerosis, varicose veins, phlebitis, arrhythmias, high or low blood pressure, heart disease, recent heart attack or stroke, anemia)

_____ Neurologic condition (e.g. numbness or tingling in any area of the body, sciatica, damage from stroke, epilepsy, multiple sclerosis, cerebral palsy)

_____ Digestive conditions (e.g. ulcers)

_____ Constipation, Diarrhea

_____ Skeletal conditions (e.g. osteoporosis, bone cancer, spinal injury)

_____ Immune conditions (e.g. chronic fatigue, HIV/AIDS)

_____ Headaches (e.g. tension, PMS, migraine)

_____ Cancer, Tumors

_____ Emotion difficulties (e.g. depression, anxiety, panic attacks, eating disorder, psychotic episodes).

Are you currently seeing a psychotherapist for this condition? Yes No

_____ Previous surgery, disease, or other medical condition that may be affecting you now (e.g. polio, previous heart attack or stroke, previously broken bone)

Comments:

13. Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

14. Has your physician or other healthcare provider recommended massage for the conditions listed above? Yes No If yes, please explain _________________________________________________

15. Do you have any particular goals in mind for this massage session related to any if the conditions mentioned above? Yes No If yes, please explain __________________________________________

I understand that I should see a doctor or other health care provider for diagnosis and treatment of any suspected medical problem. It may be beneficial for my massage practitioner to speak to my doctor about my medical condition to determine how massage may help the healing process, and to avoid worsening the condition. I will also be asked for permission to contact my doctor, if the massage practitioner thinks that might be useful. I also understand that it is my responsibility to keep my massage practitioner informed of any changes in my health, and any medications that I may begin to take in the future. The client acknowledges being given the opportunity to ask questions before receiving any work, and question or interrupt the work at any point after the session begins.

I acknowledge having read the above and understand this document.

Signature__________________________________________ Date ____________________

Please mark the body diagrams with the following letters to indicate what you have been recently experiencing: P = Pain; T = Tightness; N = Numbness/Tingling; W = Weakness.

Next to each letter, please write a corresponding number (0 through 10) that conveys the intensity of your experience. 0=No pain, 10=Emergency Room pain

What to expect: 

New clients

•Please bring your intake forms. 

•Shorts and sports bra , loose tank top/very loose yoga pants, or exercise pants •strongly recommend variations of these clothing options for all clients. 

Please avoid using lotion or cream on skin as it will interfere with your treatment session. 

A reminder for scheduled appointment will be sent out. Please arrive 10 minutes early 

All sessions are 50-60 minutes, payment may be completed at end of session

CANCELLATION POLICY

Our cancellation policy requires that you notify us of your need to cancel at least 24 hours in advance of your

scheduled appointment time, or you will be charged the full amount of the missed appointment.

We reserve the right to charge your credit card on file for missed appointments. A receipt will be provided. However, we are unable to provide a statement with diagnostic and treatment codes for missed appointments since no therapy services were provided. This means that charges for missed appointments cannot be submitted as a claim to an insurance provider for possible reimbursement since no therapy services were provided.

Late cancellations and no-shows not only affect the finances and operations of our business, but they also deprive others the opportunity for treatment. We are best able to serve our patients when our cancellation policy is responsibly enforced.

Please sign to indicate you understand and accept our cancellation policy. We have the right to not set/hold appointments if you choose to not accept our cancellation policy.

We thank you for your understanding.

Sign _____________________________________ Date ____________

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