The Turquoise Elephant Massage Therapy Consultation Form
All information is held strictest confidence. At no given point is information disclosed or shared without your written consent. All essential fields are marked with a red asterisk. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose. Please put N/A for any question marked with an asterisk which doesn't relate to you.
Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Emergency Contact
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Doctor Name
Prefix
First Name
Last Name
Doctor Phone Number
Format: (000) 000-0000.
Doctor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Back
Next
Medical History
(Any injuries, surgeries, current aches, tensions etc)
Do you take medication?
*
Do you have allergies?
*
Have you ever been an accident (automobile, work) , and have injuries as a result of this? List Areas of usual discomfort or pain & what causes the pain.
Rate the level of pain you usually experience.
Minimum
1
2
3
4
5
6
7
8
9
Maximum
10
1 is Minimum, 10 is Maximum
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION - In circumstances where medical permission cannot be obtained, clients must give their informed consent in writing prior to treatment. (Select if/where appropriate):
Pregnancy
Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension)
Hemophilia
Medical Oedema
Any condition already being treated by a GP or another complementary practitioner
Osteoporosis
Athritis
Nervous/Psychotic conditions
Epilepsy
Recent Operations
Diabetes
Asthma
Bells Palsy
Any dysfunction of the nervous system (e.g., Muscular sclerosis, Parkinson's Disease, Motor Neuron disease)
Trapped/Pinched nerves (e.g sciatica)
Inflamed nerves
Cancer
Spastic conditions
Kidney infections
Undiagnosed pain
When taking prescribed medication
Acute Rheumatism
Other
CONTRAINDICATIONS THAT RESTRICT TREATMENT (Select if/where appropriate)
Contraindications that may restrict treatment.
Fever
Contagious or infectious diseases
Under the influence of alcohol/recreational drugs
Diarrhoea & Vomiting
Skin diseases
Undiagnosed lumps and bumps
Localised swelling
Inflammation
Varicose Veins
Pregnancy
Breast feeding
Scarred tissue (2 years for major operation 6 months for small scars)
Bruises
Abrasions
Open wounds
Mensuration (first few days of mensuration depending on how the client feels)
Hematoma
Recent Fractures (minimum 3 months)
Cervical spondylitis
Whiplash
Slipped disc
Gastric Ulcers
Hernia
After a heavy meal
Hypersensitive skin
Sunburn
Additional Medical Information
Muscular/Skeletal problems:
Back
Aches/Pain
Stiff Joints
Headaches
Other
Digestive Problems:
Constipation
Bloating
Liver/Gall Bladder
Stomach
Other
Circulation
Heart
Blood pressure
Fluid retention
Tired legs
Varicose Veins
Cellulite
Kidney Problems
Cold hands & feet
Other
Gynecological
Irregular Periods
P.M.T
Menopause
H.R.T
Birth Control
Other
Nervous System
Migraine
Tension
Stress
Depression
Other
Immune System
Prone to infections
Sore Throats
Colds
Sinuses
Other
Have you ever received a massage before? If yes, what type?
Preferred massage pressure:
Please Select
Light
Medium
Are you allergic to any oils, lotions, or ointments? If yes, Please specify.
Do you have sensitive skin?
Please Select
Yes
No
Sunburn?
Please Select
Yes
No
Please specify your skin type.
Sensitive
Oily
Dry
Normal
Aging
Combination
Other
Are you wearing any of the following?
Please Select
Contact lenses
Dentures/implants
Hearing aid
Lifestyle Questions
How much water do you drink daily?
1-2 cups
3-4 cups
6-8 cups
Other
Describe your eating habits.
Do you lead an active lifestyle?
Please Select
Yes
No
Somewhat
Do you smoke or drink?
Please Select
Yes
No
What is your overall goal you would like to achieve from this session?
Is there anything else about your health history that you think would be useful for this massage therapist to know to plan a safe and effective session for you?
Draping/covering will be used during the massage session. Only the area being worked on will be uncovered. Clients under the age of 18 years must be accompanied by a parent/guardian during the entire session.
Please indicate the areas, if any, where you are feeling discomfort and specify the areas you would like the massage therapist to focus:
Shoulders
Back
Arms
Legs
Other
Female Clients Only
Are you taking oral contraception?
Please Select
Yes
No
Are you pregnant or trying to become pregnant?
Please Select
Yes
No
Are you currently experiencing or due your menstrual cycle?
Please Select
Yes
No
Client Agreement:
I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive therapeutic massage as a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also understand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. I understand that my failure to do so may post a threat to my health and/physical well being and I hold The Turquoise Elephant Massage Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part. By my electronic signature below, I agree to the massage policy and client agreement above.
Client Signature
*
Therapist Signature
Client Signature
*
Therapist Signature
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