User:Ldichter

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Name:

Phone:

Email:

Occupation:

Date of birth:

Emergency contact...phone


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Service specific questions
Have you had a therapeutic massage before? Y N

How often do you receive massage?

Do you have any allergies? Y N list___

Skin sensitivities Y N

Are you wearing contacts, prosthetic, dentures, wig, hearing aid...

Can you lay on your back, stomach comfortably?

Are you experiencing stress...anxiety...insomnia…

Do you engage in any repetatiave motion in your work or hobbies?

Are you currently experiencing any pain...explain

What goals do you have for your session today?

Medical History
Back/Neck pain

Scoliosis

Vericose veins

Joint disorder

Arthritis (kind)

Osteo Perosis

Artificial Joint

Epilepsy

Cancer History

Diabetes

TMJ

Fibromialgia

Carpel Tunnel

Tennis Elbow

Pinched nerve

Contageous Skin Condition

Open wounds or sores

Recent Surgery

Recent Fracture

Muscular Sprains/Strains

Fever/Swollen Glands

Autoimmune disease

Allergies/Sensitivities

Heart Condition

High/Low Blood Pressure

Easy Bruising

Circulatory disorder

If Pregnant how many months?

Other medical condition your massage therapist should know.

Medical Questions
Are you currently under medical supervision? If so explain.

Are you currently seeing a chiropractor?YN

Previous surgery

Are you currently taking any medications…

What other forms of self care are a part of your preventative health care routing...ie yoga, healthy eating, acupunture, exercies etc.

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Legal/liability statements

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GENERIC EXAMPLE...TO BE REPLACED WITH REAL LEGAL JARGIN...I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform 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.