Massage Therapy Consent and Disclaimer Form

Date

Therapist

I understand that the above massage therapist does not diagnose illness, disease or any other physical or mental disorder and does not prescribe pharmaceuticals or medical treatment. It has been made clear to me that this massage therapy session is not a substitute for any medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment I may have.

Due to the fact that the massage therapist must be aware of any existing physical conditions of clients treated, I have stated any/all of my known medical conditions and if necessary give permission to the therapist to consult with my physician.

I assume all risks and perils to my person physically, physiologically or psychologically which may ensue during this or subsequent treatments. As well as any effects deemed detrimental which may ensue afterwards as a result of this or subsequent treatments.

I have read all of the above information and fully understand what has been stated and expected from me.

CLIENT’S NAME

Signature

FIRST NAME

LAST NAME

ADDRESS

POSTAL CODE

PHONE (home)

Format: (000) 000-0000.

(work/cell)

AGE

BIRTHDATE

Date

EMAIL ADDRESS

example@example.com

MANITOBA BLUE CROSS POLICY#

ID#

HOW DID YOU HEAR ABOUT US?

PHYSICIAN

CHIROPRACTOR or PHYSIOTHERAPIST

PRIMARY REASON FOR APPOINTMENT

HAVE YOU EVER HAD A THERAPUTIC MASSAGE BEFORE?

Do you have a current health status or a history of any of the following? If YES please indicate.

Heart Problems, Chest discomfort/pressure pain, Heart disease?

YESNO

Sudden tingling, Numbness in arms, hands, chest, face, feet or legs?

YESNO

Told that you have high or abnormal blood pressure?

YESNO

Respiratory or breathing problems (asthma, allergies, bronchitis)?

YESNO

Diabetes? If so how is it controlled?

YESNO

Diabetes? If so how is it controlled?

DietOral medicationInsulin injectionsuncontrolled

Faintness, Dizziness, Lightheadedness or Blackouts?

YESNO

Have frequent headaches?

NOYES

Wear contact lenses?

NOYES

Have varicose veins?

YESNO

Have arthritis or osteoporosis?

NOYES

Joints affected

Ever had cancer?

YESNO

Type?

Chronic diarrhea or constipation?

YESNO

Currently taking any medications?

NOYES

If so. What are they?

Suffered from a severe injury or have you been hospitalized

NOYES

Suffered from a severe injury or have you been hospitalized

Received Cortisone injections? If so when and where?

NOYES

If so when and where?

Any skin conditions or reactions to lotions or creams?

YESNO

If so pleast list any skin conditions or reactions to lotions or creams?

Have concerns about your sleep pattern, appetite or current level of stress? Please describe briefly.

Dominant Side

RL

Please use the left or right side of body to

indicate the area(s) which is

currently problematic for you. Please be as

Specific as possible

Do you indicate any tingling or numbness anywhere?

Do you indicate any swelling or loss of mobility anywhere?

Do you indicate any heat or burning anywhere?

Do you indicate any Pain anywhere?

Occupation

Types of physical activities involved

Recreational activities and interests

Client expectation/goals of treatment

Therapist expectation/goals of treatment

The client and therapist have understood and agreed upon realistic expectations and goals of treatment. These outcomes will be reviewed and updated at the beginning of each session.

Massage Therapy Consent and Disclaimer Form

CLIENT HISTORY

CURRENT HISTORY

LIFESTYLE

EXPECTATIONS