Movement in Massage
New Client Health History
Name
*
First Name
Last Name
Gender
*
Please Select
biological male
biological female
Who referred you?
*
Do we have permission to share session notes with your referring provider
*
Please Select
Yes
No
Perhaps at a later time with written consent
No one referred me
Date of Birth
*
 -
Month
 -
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Occupation
Hours worked/wk
Enjoyed Hobbies
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Areas of Functional Concern
*
Movement in Massage and its practitioners do not treat or diagnose. Any information learned remains confidential and is considered for the approach of techniques used during treatment.
Areas of stress in the past 2 years (select any that apply)
*
grief or loss
new birth
work or job demands
family situation
moving
relationship
life change
hormonal body changes
sickness or injury
none known
Other
Other stressor:
Any surgeries in the last 5 years. List the month and/or year of surgery and what it was addressing, or type "N/A" if no surgeries
*
Please upload files here if you have access to surgical notes or images:
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Past history: Any surgeries in the life of the patient. List the month and/or year of surgery and what it was addressing. This is particularly helpful for understanding "seemingly-unrelated" restrictions during bodywork.
*
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Select all that apply in the past 0-6 months:
*
slow digestion/constipation
fast digestion/diarrhea
acid reflux or heartburn
stomach upset
gall stones
kidney stones
pain/tension around right shoulder blade or right ribs
sinus infections
sinus or breathing allergies
sleeping poorly
dental work
food allergies
environmental allergies
headaches
jaw tension
hard fall
broken or fractured bone
illness
tendon/ligament injury
dizziness
none of the above
unexplained pain
Other
Other:
Select all that have applied at any time in life EXCEPT the past 6 months:
*
slow digestion/constipation
fast digestion/diarrhea
acid reflux or heartburn
stomach upset
gall stones
kidney stones
pain/tension around right shoulder blade or right ribs
sinus infections
sinus or breathing allergies
sleeping poorly
dental work
food allergies
environmental allergies
headaches
jaw tension
hard fall
broken or fractured bone
illness
tendon/ligament injury
dizziness
none of the above
unexplained pain
Other
Other:
Additional areas of concern:
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Current medications and what they are addressing:
*
Allergies: i.e. oils, lotions, food, medications...
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Women: (select all that apply) have/had,
*
current pregnancy
birth(s)
c-section(s)
none of the above
Does not apply to me
Months along in pregnancy
Women's health, current hormonal lifestage:
*
experiencing periods
on birth control
have an IUD
peri-menopause
menopause
post-menopause
partial or complete hysterectomy
hormone replacement therapy
none
Does not apply to me
Other
Women's pelvic floor health
*
vaginal tearing
pelvic floor/vaginal prolapse
bladder leaking
none
Does not apply to me
Other
Women's past history:
*
have had an IUD
have been on birth control
have received hormone replacement therapy
none of the above
does not apply to me
Other
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Men's Health: have experienced,
*
bladder urgency
prostate changes
none
Does not apply to me
Other
I am concerned with the above health changes,
Please Select
1. Not at all
2. Somewhat
3. Very much
4. Does not apply to me
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Your therapist may use any or all of the techniques below, at their discretion, to move toward increased function, mobility, and/or decreased stress for physical/neurological wellbeing. Please help your therapist understand what techniques you have experienced by selecting options below:
*
I understand therapist will choose techniques for the session
I have received Visceral Manipulation (VM= releasing restriction and increasing mobility of the organ tissue), or Visceral-Vascular work (VV= releasing restriction and increasing function of the vascular system/arteries). VM is a very gentle and effective technique to address various restrictions that may have been caused by, but not limited to: scar tissue, hiatal hernia, past infection, discomfort during/after pregnancy, unexplained pain, etc.
*
first time
I have received VM before
I am unsure if I have received this before
I have received Myofascial work (MFR= releasing restriction of the fascia/connective tissue which is throughout the body), or Neuromuscular and/or Trigger Point work (NMT/TP =releasing restriction of the spindle cells and golgi tendons in muscles)
*
first time
I have received MFR before
I am unsure if I have received this before
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Movement in Massage Agreement
read and sign
I understand that Movement in Massage (MiM) keeps all records and treatment information confidential unless given prior, written notice by myself, the client, (or) unless subpoenaed for court records. My therapist at MiM is not qualified to treat or diagnose, and does not perform spinal manipulations. I will effectively communicate any concerns before and/or during my session. MiM may give homecare exercises and suggest reading material and practical or nutritional resources for my continued care; I understand it is my responsibility to consider these resources as voluntary and administered only under guidance of other qualifying practitioners. I have provided true and accurate health history information to the best of my ability. Massage Therapy and its techniques are provided for therapeutic and functional benefits alone; sexually elicit comments or advances will result in immediate termination of care and be subject to full charge of session. MiM reserves the right to refuse or dismiss care of any client and/or refer a client to another provider. MiM keeps notes of techniques used and health updates for only some sessions. As a medical massage practice, sessions at Movement in Massage are focused on being functional, compassionate, and therapeutic. Payment is due in full at the time of service. Cancelations within 48hrs may be subject up to full payment amount. Policies and prices may be updated without notice.
*
I agree, and consent to care
My signature reflects compliance with the above agreement. If I am the parent/guardian of the minor who's detail are listed above, I give permission for my child to receive bodywork:
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