Name:________________Telephone:( )________Date of Birth__/__/___
Address:______________________City________State____Zip_______
Emergency contact:__________________________Telephone( )_____
Referred By:___________________________________
GENERAL AND MEDICAL INFORMATION
Please take a moment to carefully read the following, if you have a specific medical condition or specific symptoms massage may be contraindication. Practitioner may terminate session!
Occupation:_____________________________________Age:_____ Male Female
Physician Name_____________________________ Health Insurance Carrier____________________.
Have you ever experience a professional massage/bodywork session Yes No How recently_____
Yes No Do you have any other medical conditions that we should know or medications that you are taking that could be a contraindication, please Specify?
Yes No Have you had surgery past year, please explain.
Yes No Have you had in the past 2 years, car accidents or suffered any injuries, broken bones, back pain, stabbing pain, tension/soreness in specific area, please specify:
Yes No Do you have or frequently suffer from: stress, headaches, bruising, arthritis, sensitivity to touch, joint swelling, pregnant, wearing contacts, high blood pressure, osteoporosis, allergies, varicose veins, nerve pain, if yes please explain.
I understand that the Massage/Bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain/discomfort during this session, I will immediately inform the practitioner, and a adjustment will be made to my level of comfort.
I understand that the Massage Practitioners are not qualified to perform spinal or skeletal adjustments.
I understand that Massage Practitioner should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see my Primary Care Person or other qualified medical specialists for any physical or mental ailment that I am concerned or aware of. That I have stated all my known medical conditions and answered all questions honestly. I agree to keep the Massage Practitioner up to date as to any changes in my medical profile and understand that there shall be no liability on the Massage Practitioner's part should I fail to do so.
I further understand that any illicit or sexually suggestive remarks or advances made my me will result in the immediate termination of the session, and I will be liable for payment of the scheduled appointment.
CLIENT'S SIGNATURE___________________________________________________________Date:_______
Practitioner Signature:_____________________________________________________________Date_______
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CONSENT TO TREATMENT OF MINOR: By my signature below, I hereby authorize___________________________ to administer massage, bodywork, somatic therapy techniques to my child or dependent as they deem necessary. Signature of Parent/Guardian_______________________________________________________Date:__________ Print Parent/Guardian Name:______________________________________________ |
