Massage Questionaire

MASSAGE & TREAMENTS QUESTIONARY

216 Newtown Road NE, Calhoun 30701
Personal Information
In order to serve you properly, please fill out all information below as accurately as possible. This information will help to plan a safe and effective massage session. Please answer your questions to the best of your knowledge.
Full Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Phone Number *
Type only the numbers. No (,),/,-
Medical History

In order to serve you properly, please fill out all information below as accurately as possible. This information will help to plan a safe and effective massage session. Please answer your questions to the best of your knowledge.
Have you ever had a professional massage?

No Yes, How often?:
Are you pregnant? (If applicable)

No Yes, How far along?:
Do you have any allergies to oils, lotions, or ointments?

No Yes, please list:
Please list any medication you are currently taking: *
Have you had any surgery? *

No Yes, please list which one and when:
Do you suffer from seizure disorders or epilepsy? *

No Yes, please explain:
Do you experience frequent headaches? *

No Yes, how often?
Do you have cardiac or circulatory problems? *

No Yes, please describe:
Please describe any broken bone in the past 2 years:
Do you have numbness or stabbing pains? *

No Yes, please describe:
Do you have any difficulty lying on your front, back, or side? *

No Yes, please describe:
Do you sit for long hours at a workstation, computer, or driving? *

No Yes, please describe:
Do you perform any repetitive movements in your work, sports, or hobby? *

No Yes, please describe:
Is there a particular area of the body where you are experiencing tension, stiffness, pain? Or other discomfort?: *
Pain Frequency - Please select the most accurate and describe if needed:

Constant Off/On At Rest With Any Motion
At what time of the day is the pain at its worse?

Morning Afternoon Evening During Sleep
Have you ever injured this area before? *

No Yes, explain:
Do you have any mental illness? *

No Yes, explain:
Do you have cardiac or circulatory problems? *

No Yes, explain:
Are you wearing:

Hearing aids Dentures Contact lenses
Have you ever been in an accident (automobile, work, etc.) *

No Yes, when?
Past History:

Arthritis Asthma Diabetes I Diabetes II Emphysema Glaucoma Hay Fever, Allergies Heart Disease Hiatal Hernia or Reflux Disease High Blood Pressure HIV Kidney Disease Liver Disease or Hepatitis Pneumonia or Pleurisy Prostate Problems Pneumatic FeverStroke Sinus Problems Thyroid Problems Tuberculosis or Exposure to TB Ulcers of the Stomach or Duodenum Urinary Infection, Bladder, or Kidney Base of skull Dizziness Fainting Light-headedness Pain in ears Ringing in ears Cancer
Personal Habits:

Alcohol Tobacco Soft Drink Coffee/Tea
Do you have any particular goals in mind for this session? *
Type NA if none
PROHEALTH DISCLAIMER
- Your scheduled session is set aside for you.
- You will be draped and at no time will genitalia or breast tissue be exposed.
- You will have a consultation with your therapist to discuss your session.
- After your therapist has left the room, you may disrobe to your comfort level.
- I understand that my therapeutic massage therapist or I may end the session at any time for any reason.
- Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law.
- If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service provided.
- 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 or discomfort during this session. I will immediately inform the therapist 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 consult a physician, chiropractor, or another qualified medical specialist for any mental or physical ailment that I am aware of.
- I understand that massage /bodywork therapists 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 therapist updated as to any changes in my medical profile and understand that there shall be no result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Agreement to ProHealth Disclaimer *
Signature *

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MASSAGE & TREAMENTS QUESTIONARY

Medical History