Massage

First Name Last Name

DOB

Street Address Address Line 2 City State Zip

Phone Number

Please enter a valid phone number.

How did you hear about Hands of Therapy?

Are you pregnant?

YesNoN/A

How many weeks?

Any pregnancy high risk factors? Please explain.

During pregnancy, are you experiencing any of the following? If so, please check any that apply.

Pitting edemaHigh blood pressurePreterm labor: symptoms include uterine or abdominal cramping with or without vomiting or diarrhea, vaginal bleeding, and change in vaginal discharge. Or pelvic pressure, low back pain, and intermittent or persistent pain in front of thighs.Uterine bleeding or stainingSevere abdominal painNo fetal movement for 8-10 hoursThrobbing headaches or severe migrainesPlacenta previaPlacenta abrupta

Have you recently had an invasive prenatal diagnostic test?

Yes

Cancer (past or present)

PastPresent

What type of cancer do/did you have? Please describe the type and location.

What was the date of diagnosis and when did you finish treatment?

What type of treatment did/do you have?

Do you have any medical devices or colostomy bag?

Do you have any positioning needs due to:

Did you have any lymph nodes removed?

YesNoNot sure

Describe your activity level? (include info about work, exercise, interests, or hobbies)

Any bone or joint problems associated with cancer?

osteoporosisarthritisbone metastasis

Any injuries associated with cancer?

AccdientstendonitisfracturesOther

Neuropathy that is associated with cancer?

YesNoYes but not associated with cancer

Digestive problems associated with cancer? (such as colitis, IBS, constipation, or diarrhea)

Hematological conditions? (such as anemia, low white blood count, low platelets)

For those with cancer, are you experiencing any of the following?

Blood clots

Yes

HIV/AIDS

Yes

Herniated Discs

Yes

Heart condition

Yes

What kind of heart condition?

Stroke

Yes

Deep Vein Thrombosis

Yes

Have you been cleared of the blood clot by a DR?

YesNo

Are you on blood thinners? What is the reason for blood thinners?

Kidney Disease

Yes

Multiple Sclerosis

Yes

Hypertension

Yes

Autoimmune Disease

Yes

Contagious condition

Yes

Decreased sensation

Yes

Diabetes

Yes

Osteoarthritis/Osteoporosis

OsteoarthritisOsteoporosis

Seizures

Yes

Organ failure

Yes

Please explain here any of the conditions above if you have extra info to give.

Have you been diagnosed with any other medical conditions not listed above?

Are you taking any medications and what is their purpose?

Have you had any medical procedures within the last year? Please explain. Associated with cancer or non cancer surgical procedures.

List of medical treatments from cancer. (such as radiation, chemo, or physical therapy and please include dates)

Have you had any joint replacements? Please explain.

Have you recently had any botox done?

Yes

If so, please indicate how long ago.

Have you ever had a massage?

YesNo

Reason for visit

RelaxationPain reliefAll of the above

If you have pain, where are you experiencing the pain?

What activities recreate the pain?

How would you describe the pain?

SharpDullAchingNumbness

What type of pressure do you like?

LightMediumFirmNot sure

I understand the massage I receive by Crista Shumaker is for relaxation and/or the relief of muscular tension. If I experience any discomfort during the session, I will immediately inform Crista Shumaker so that the pressure and strokes may be adjusted. Crista Shumaker advises the client to speak with their doctor before receiving massage therapy to ensure massage therapy is advised for their condition. Crista Shumaker reserves the right to refuse or terminate the massage session to anyone whom she considers having a condition(s) for which massage is contraindicated. I also understand that any illicit or sexually suggestive remarks or advances made by me(the client) will result in immediate termination of the session. By signing below, I will not hold Crista Shumaker liable for any risks of massage therapy and I have completed this form to the best of my knowledge.

For those with cancer: I realize that this session is being given for the purpose of relaxation and comfort. I agree to communicate wilth the therapist anytime that I am uncomfortable or that I feel my well-being is compromised. I have listed all of the medical conditions that I am aware of.

For cancer clients: My doctor is aware that I receive massage.

YesNo

Signature

Date

Form

Client Information

Health Information

Check any that apply. Please be advised that I do not massage anyone with contraindications.

Massage Information

Consent Form