Health Information
Thank you for taking the time to complete and submit this form.
Client Contact Information
Client Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Client Date of Birth
-
Month
-
Day
Year
Date
Gender
Client Occupation
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Referred by
Emergency Contact Name/Relation
Emergency Contact Number
Please enter a valid phone number.
Physician/Health-Care Provider Name
Physician/Health-Care Provider Phone Number
Please enter a valid phone number.
Is this massage/bodywork medically necessary (medical condition, injury, surgery, etc.)?
Please Select
Yes
No
Do you have a physician referral/prescription?
Please Select
Yes
No
Are you seeking insurance reimbursement? If yes, please complete the Insurance Verification form.
Please Select
Yes
No
Click here to complete the Insurance Verification Form
Type of insurance coverage for this claim:
Please Select
Car Collision
Worker's Compensation
Private Health
Other
Massage Information
Have you ever received professional massage/bodywork before?
Please Select
Yes
No
If so, how recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer?
Please Select
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
How do you feel today?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc):
Do these symptoms interfere with your activities of daily living (e.g. sleep, exercise, work, childcare)?
Please Select
Yes
No
If yes, please explain:
List any prescription medications and/or supplements you currently take:
Are you wearing contacts?
Please Select
Yes
No
Are you wearing dentures?
Please Select
Yes
No
Are you wearing a hairpiece?
Please Select
Yes
No
Are you pregnant?
Please Select
Yes
No
Health History
What is your height?
What is your weight?
Have you had any injuries or surgeries in the past that may influence today's treatment?
Select any of the following health conditions that you currently have (if you are unsure, please ask):
Blood Clots
Infections
Congestive Heart Failure
Contagious Diseases
Pitted Edema
Please answer honestly, as massage may not be indicated for the above conditions.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received in the comments section below.
Muscle or Joint Pain
Please Select
Current
Past
N/A
Muscle or Joint Stiffness
Please Select
Current
Past
N/A
Numbness or Tingling
Please Select
Current
Past
N/A
Swelling
Please Select
Current
Past
N/A
Bruise Easily
Please Select
Current
Past
N/A
Sensitive to Touch/Pressure
Please Select
Current
Past
N/A
High/Low Blood Pressure
Please Select
Current
Past
N/A
Stroke, Heart Attack
Please Select
Current
Past
N/A
Varicose Veins
Please Select
Current
Past
N/A
Shortness of Breath, Asthma
Please Select
Current
Past
N/A
Cancer
Please Select
Current
Past
N/A
Neurological (e.g. MS, Parkinson's, Chronic Pain)
Please Select
Current
Past
N/A
Epilepsy, Seizures
Please Select
Current
Past
N/A
Headaches, Migraines
Please Select
Current
Past
N/A
Dizziness, Ringing in the Ears
Please Select
Current
Past
N/A
Digestive Conditions (e.g. Crohn's, IBS)
Please Select
Current
Past
N/A
Gas, Bloating, Constipation
Please Select
Current
Past
N/A
Kidney Disease/Infection
Please Select
Current
Past
N/A
Arthritis (Rheumatoid, Osteoarthritis)
Please Select
Current
Past
N/A
Osteoporosis, Degenerative Spine/Disk
Please Select
Current
Past
N/A
Scoliosis
Please Select
Current
Past
N/A
Broken Bones
Please Select
Current
Past
N/A
Allergies
Please Select
Current
Past
N/A
Diabetes
Please Select
Current
Past
N/A
Endocrine, Thyroid Conditions
Please Select
Current
Past
N/A
Depression, Anxiety
Please Select
Current
Past
N/A
Memory Loss, Confusion, Easily Overwhelmed
Please Select
Comments
Consent for Treatment
Terms and Conditions
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 during the session should be constructed 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 the 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.
Client Signature or Parent/Guardian Signature (in case of a minor)
By signing here, I state that I have read and understood the terms and conditions.
Date
-
Month
-
Day
Year
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