Name:___________________________________ Telephone:___________________ D.O.B.________________
Address:_________________________________ City:__________________ State:_____ Zip:______________
Referred by:______________________________ Telephone:_________________
In case of emergency:_______________________ Telephone:_________________
General & Medical Information
Occupation:______________________ Age:_____ M/F (circle) Physician:______________________________
Health Insurance Carrier:_____________________________________________________________
The following questions need to be looked over to determine whether or not massage is contrainnicated.
y/n Do you frequently suffer from stress?
y/n Do you have diabetes?
y/n Do you experience frequent headaches?
y/n Are you pregnant?
y/n Do you suffer from arthritis?
y/n Do you have high blood pressure?
y/n Are you taking medication? Please attatch list or explain:
_______________________________________________________
y/n Do you have any contagious diseases? If so, please specify:
_______________________________________________________
y/n Do you suffer from epilepsy or seizures?
y/n Do you suffer from joint swelling?
y/n Do you have vericose veins?
y/n Do you have osteoperosis?
y/n Do you have any allergies?
y/n Do you bruise easily?
y/n Have you had any broken bones or suffered injuries in the past two years?
y/n Do you have soreness in a specific area? Please, explain:
__________________________________________________________
y/n Do you have heart problems?
y/n Have you ever had any surgery? Explain below.
___________________________________________________
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 this session, I will immediately inform the practitioner 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, chiropractor or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners 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 too keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so, I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Client Signature_________________________________________________Date____________
Practitioner Signature_____________________________________________Date____________
Consent to Treatment of Minor: By my signature below, I hearby authorize______________________________ to administer massage techniques to my child or dependent as they deem necessary.
Signature of Parent or Guardian_____________________________________ Date____________