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Who is filling out this form?*

SelfGuardianHealthcare/Social WorkerOther
Clients Name and First Initial of Last Name*
First Name and the First Initial of Last Name (ex. Johanna J.)
Date of Birth*

MonthDayYear
Phone*
E-mail*
example@example.com
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The preceding list of conditions require adaptations to Massage Therapy. Please advise if you require any adaptations on account of the following*

Based on this list, I require adaptations.Based on this list, I do NOT require adaptations.

	Yes	No	Notes/Remarks
Do you have a broken bone?
Do you have strains or sprains?
Are you using a wheelchair, cane or crutch?
Have you been hospitalized due to a recent injury?
Have you undergone any recent surgery?
Do you have any allergies? (Please List)
Are you taking any medications? (Please List)
Are you taking any herbal supplements, vitamins or minerals? (Please List) (Please List)
Do you wear dentures?
Do you wear contact lenses?
Do you have any surgical implants, replacements, rods or stints within your body?