Massage Health History Form

Have you have any surgeries or injuries within the past 12 months? Please Explain

Do you currently have any of the following health issues

Blood Clots Congestive Heart Failure Contagious Disease Infections

Please indicate any conditions that you currently have or have has in the past 12 months

Muscle or joint pain Bruise easily Sensitive to touch or pressure Stroke or heart attack Varicose veins High/low blood pressure Shortness of breath or asthma Cancer Neurological Problems (i.e MS, Parkinson's, chronic pain) Epilepsy, seizures Headaches, Migraines Dizziness, ringing in the ears Digestive issues Kidney Disease Arthritis Osteoporosis, Degenerative spine/disk Scoliosis Broken Bones Allergies (i.e Food, scents, environmental) Diabetes Thyroid Conditions Depression , anxiety

Please explain any of the above

Have you had any Rash or Blisters that have appeared on your body within the last 14 days? *

Yes No

If yes to the above question please explain.

Are you at least 18 years old? *

Yes No

*If you are not 18 years of age, you will be required to have a parent or guardian present at the time of your appointment.

Renewed Skin and Body Cancellation policy is as follows:

A credit card is required to book your appointment, this card holds your appointment. In the event that you no-show or late cancel your appointment less than 24 hours before your appointment time, your card will be charged a fee. Fees vary depending on the appointment(s) booked.

Inputing your card during the booking process, does not pay for your service(s), it simply holds your apoointment.

Initial that you understand our cancellation policy *

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/bodywork 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/bodywork 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/bodywork 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 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. Understanding all of this, I give my consent to receive care

Date

Signature *

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