Balance Massage & Wellness Center Client Health Questionnaire

Balance Massage & Wellness Center Client Health Questionnaire

Please complete to the best of your knowledge
Your privacy is important. All information provided is kept in strictest confidentiality.
First Name*
Last Name*
Address*
Apt
City*
State*
Zip*
Daytime Phone*
Evening Phone*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
In Case of Emergency, Please Notify*
Relationship to Client*
Phone*
How did you find us? Google, other online search, direct referral (provide their name here so we can thank them with $15 BMWC Cash)
Occupation*
Employer*
Do you sit for long hours at a workstation, computer, or driving?*

YesNo
Do you perform any repetitive movement in your work, sports, or hobby?*

YesNo
Have you ever received a massage before? If yes, when was your last session?*
Is there a particular area of the body where you are experiencing tension, stiffness, or other discomfort?*

YesNo
Do you have any difficulty lying on your front, back, or side?*

YesNo
Do you have allergic reactions to oils, lotions, ointments, liniments, or other substances put on the skin?*

YesNo
Do you have any particular goals for this massage session? *
You are aware that you will be draped during the entire session?*

I understandI do NOT understand and require explanation
Initials*
Date*

MonthDayYear
Date
All cancellations with less than 24 hours notice may be subject to billing at the full rate.
Check any and all of the following general health conditions that currently apply to you, or have occurred within the last 12 months.*

Allergies (food, seasonal, medication, other *list below*)AsthmaBlood clotting disorderCancerCardiac ConditionChronic fatigueCirculation concerns, cold hands/feetConfusion/forgetfulnessCosmetic/reconstructive surgeryDiabetesDizziness/faintingEhlers-Danlos SyndromeEpilepsyFibromyalgiaGI ConditionsHeadachesHearing impairedHigh blood pressureLow blood pressureLymphedemaMultiple sclerosisNumbness and/or tinglingPacemakerParkinson's DiseasePelvic Considerations (prostate, UTI, endometriosis, pelvic inflammatory disease, hysterectomy)Shortness of breathSkin condition (moles, acne, rash, herpes/shingles, ezcema, pressure sores, psoriasis)Sleep disorderStrokeVaricose veinsVisually impairedNONE OF THE ABOVEOther
Provide Additional Information:
Menstruating/Pregnant Clients
Infectious/communicable diseases please list below (this may necessitate a reschedule of your session):
Check any and all of the following musculoskeletal conditions that currently apply to you, or have occurred within the last 12 months.*

ArthritisBack painBone/joint diseaseBroken/fractured bonesBursitisChronic PainDifficulty walkingFoot/ankle plainHerniated DiscJaw pain/TMJJoint replacementJoint stiffness/swellingLeg/hip/knee painMultiple SclerosisMuscle spasms or crampingMuscular DystrophyNeck painOsteoporosisParalysisParkinson's DiseasePinched NerveScoliosisShoulder/arm painSpinal Cord InjuryTendonitisNONE OF THE ABOVEOther
Provide Additional Information:
Other congenital or acquired disabilities that we should be aware of?
Are you under Medical, Chiropractic, Physical Therapy, or Therapeutic treatment?*
Do I have permission to contact your doctor or other healthcare provider, if necessary?*

YesNo
Primary Care Providers Name, Address, and Phone Number:*
Please list ANY prescription medications that you are currently taking: *
Please list ANY herbal/nutritional supplements that you are currently taking: *
Assistive Devices:

Contact lensDenturesHearing aidOther
If there is any addition information that you think we should know prior to your appointment, please provide details below:
{typeA}Please provide any comments/concerns regarding your present condition:

{initials}I have stated all conditions that I am aware of and the information I have provided is true and accurate. I will provide updates regarding any changes in my health condition, medications, supplements, or allergies.
Signature

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Date

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Date
Balance Massage & Wellness Center

Policies and Procedures Agreement

1. If a cancellation is necessary, please give at least 24 hours notice. No-shows may be charged the full fee, except in cases of emergency or if I can fill the slot with another client.

2. If there is an emergency and the therapist cannot make your appointment, they will try to reach you by phone.

3. Please be on time and respectful of the next person who may be waiting for their appointment to start on time. Clients should be on the table and ready for their massage by five minutes after their appointment time. If a client is late, she/he may lose some of her/his time. If the therapist is late, she/he will compensate you for your time.

4. Clients are always draped between the sheets. This serves a dual purpose: to keep muscles warm that may have been massaged, and to protect the client's modesty.

5. Clients will determine how much clothing they feel comfortable removing. 6. The massage that you will receive is a non-sexual massage. It should also be clear that the service and intent of massage therapy is in no way similar to that of the so-called "massage parlors."

I understand that massage therapy is the manipulation of the soft tissues for therapeutic purposes. Massage therapy is not meant to replace medical treatment, should the need arise. I further understand that any medical diagnosis of my condition must be performed by a licensed medical practitioner and that I am advised to seek more appropriate treatment where indicated. I assume full responsibility for such consultation if necessary. I understand that massage therapy makes no claims to "cure" my condition.

I understand that I am responsible for communicating any physical or emotional discomfort, if any should arise, during the massage session. This may include, but is not limited to, temperature of room, music, depth of pressure, etc. My signature below acknowledges that I have read, understand, and agree to adhere to the above policies.
Clients Signature

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Date

MonthDayYear
Date
Should be Empty: