Questionnaire - English

Name*
Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Date Of Birth:*

MonthDayYear
Employer:*
Occupation:*
Emergency Contact:*
Phone: *
Please enter a valid phone number.
Relationship:*
Referred By:
Email*
Is This Your First Professional Massage?*
If No, How Frequently Do You Get A Massage?
What Do You Hope To Accomplish From Today's Massage?*
Are You Aware Of Any Tension Holding Spots In Your Body?*
If Yes, Location(S)
Describe Any Surgeries, Hospitalizations, Accidents Or Injuries You Have Had:
Less Than 5 Years Ago:
More Than 5 Years Ago:
What Kind Of Care Did You Receive For Your Accidents Or Injuries?
Do You Feel That You Have Recovered From These Events?
Please Explain:
Do You Have Any Chronic, Ongoing Pain That You Deal With On A Regular Basis?*
Please Explain:
Describe What Activities Cause This Pain And/or Make It Worse:
Are You Receiving Any Other Type Of Medical Treatment?*
Please Explain:
Please List Any Medication (Vitamins, Herbs Or Pharmaceutical) Taken Now Or At Regular Intervals (Include Explanation Of What Medication Is Used To Treat):*
Are You Currently Under The Care Of A Physician?*
Whom?
Please List Reason(S):
Are There Any Other Health Concerns You Wish To Discuss Today?*
If Yes, Please Describe:
Are you currently experiencing any of the following conditions?

Flu or ColdInflammationFeverInfectionContagious Disease
Additional details:
Please check any of the following conditions below that currently affect you or that you have experienced in the last 5 years.
Musculoskeletal

FibromyalgiaSpasms/CrampsSprains/StrainsOsteoporosisPostural DeviationsGoutOsteoarthritisaheumatoid ArthritisTMJCystsCystsPlantarFascitisTendonitisTorticollisWhiplash SyndromeCarpal Tunnel SyndromeSciaticaThoracic Outlet SyndromeHeadacheLeg PainArm Pain/shoulder PainLow Back PainMid Back PainHip PainOther
Additional details:
Respiratory

PneumoniaSinusitisAsthmaTrouble BreathingDizzinessOther
Additional details:
Circulatory

AnemiaHemophiliaHypertensionLow Blood PressureRaynaud's DiseaseVaricose VeinsHeart ConditionBlood Clots/phlebitisDiabetesOther
Additional details:
Digestive

UlcersIrritable Bowel SyndromeColitisGallstonesHepatitisCrohn's DiseaseDiarrheaGas/bloatingIndigestionOther
Additional details:
Skin

Fungal InfectionsAcneImpetigoDermatitis/eczemaPsoriasisOpen Wound Or SoreRashesWarts/molesAthletes FootOther
Additional details:
Nervous System

ALSMultiple SclerosisParkinson's DiseaseBell's PalsyNeuritisSpinal Cord InjuryStrokeTrigeminal NeuralgiaSeizure DisordersNumbness/tingling/twitchingOther
Additional details:
Other

InsomniaAnxiety/panic AttacksPMSGrief ProcessCancerSubstance AbusePregnancyChronic FatigueHiv/aidsLupusKidney DiseaseBladder InfectionPostoperative SituationEdemaOther
Additional details:
The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications bones. I further understand that message therapy is not a substitute for medical attention or examination. I take responsibility for altering my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointment without 24 hours notice (medical emergencies excluded) may be charged in full for the price of the missed session.*

I agree
Signature:*
Date*

MonthDayYear
Before Your Appointment
Please check any that apply to you:

- HAVE YOU HAD A NEW OR WORSENING COUGH?- HAVE YOU HAD A FEVER?- HAVE YOU HAD SHORTNESS OF BREATH?- HAVE YOU BEEN IN CLOSE CONTACT WITH ANYONE WITH THESE SYMPTOMS OR ANYONE WHO HAS BEEN DIAGNOSED WITH COVID-19 IN THE PAST 14 DAYS?
- IF YOU ANSWERS “YES” TO ANY OF THE QUESTIONS ABOVE, I WILL NEED TO RESCHEDULE YOUR APPOINTMENT UNTIL YOUR SYMPTOMS (COUGH, FEVER AND SHORTNESS OF BREATH) HAVE BEEN RESOLVED, FOR AT LEAST 14 DAYS AFTER AND IF YOU THINK YOU HAD CONTACT WITH A PERSON SICK WITH COUGH, FEVER, OR DIAGNOSED COVID-19.
- WE RESERVE THE RIGHT TO CANCEL UPON YOUR ARRIVAL IF NECESSARY.
- THE DOOR WILL REMAIN CLOSED JUST TEXT OR LEAVE A MESSAGE WHEN YOU ARE OUTSIDE. I WILL CONTACT YOU WHEN READY FOR YOUR APPOINTMENT.
- WE ARE FOLLOWING ALL RECOMMENDED OSHA, AMTA AND CDC GUIDELINES, WE ASK THAT YOU WEAR A MASK DURING YOUR VISIT ( IF YOU DO NOT HAVE ONE THERE WILL BE SOME AVAILABLE FOR YOU AT 1.50 EACH)
- PLEASE DO NOT MAKE YOUR APPOINTMENT RIGHT AFTER EXERCISING.
- REVIEW AND FILL OUT FORMS ON LINE BEFORE YOUR APPOINTMENT.
- ONLY THE PERSON WITH THE APPOINTMENT WILL BE ALLOWED IN, EXCEPT SPECIAL NEED CLIENTS.
Signature:*
Covid-19 Liability Waiver
Unfortunately, even with the most rigorous sanitation protocols, enhanced client screening, and social distancing precautions, there is still risk of COVID-19 transmission involved. I understand that, because massage therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless Milagros Altamirano LMT 1211 at Massage and Cranial Release Therapy Center from any claims related thereto. I give my consent to receive treatment from this practitioner.*

I agree
Signature:*
Date:*

MonthDayYear
Parent or Guardian Signature (In case of Minor):
Milagros Altamirano LMT 1211

Massage Cranial Release Therapy Center
Should be Empty:

Before Your Appointment

Covid-19 Liability Waiver