Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Person
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Medical Condition
Do you have any recent surgeries, including plastic surgery?
*
Are you currently taking any medications? If yes, please list them below.
*
Do you have any allergies? If yes, please list them below.
*
Do you have any of the following?
Rows
Yes
Details of Condition
High Blood Pressure (Hypertension)
Arrhythmias or Irregular Heart Beats
Swelling (Edema)
Lung Disease (Pulmonary)
Congestive Heart Failure (CHF)
History of Heart Attack (MI)
Abnormal EKG
Kidney Disease
Anemia
Asthma
Bleeding/Clotting Disorder
Diabetes
History of Stroke
History of Anxiety
Night Sweats
Sudden Weight Loss
Skin Disorder
Do you have any health conditions that were not listed
Are you currently pregnant or breastfeeding?
*
Yes
No
Have you recently or are you currently experiencing shortness of breath, chest pain/discomfort?
*
Yes
No
Have you recently or are you currently experiencing swelling (edema)?
*
Yes
No
Have you had a massage before?
Yes
No
What type of massage are you seeking?
What type of pressure do you prefer?
Light
Medium
Deep
Do you have any specific areas of tension, pain or discomfort? You would like for me to focus on during in your session?
Are there any areas you do not want Massage?
Acknowledgment
Check all that apply:
*
I understand that massage therapy is intended for relaxation and therapeutic purposes and is not a substitute for medical care.
I will communicate my preferences, discomfort, or concerns before or during the session. I will inform the therapist of any health conditions or changes in my health
I understand that I will be properly draped at all times and only the area being worked on will be uncovered.
I understand that any inappropriate behavior will result in the immediate termination of the session, and I may be refused future services.
My personal and health information will be kept confidential and will not be shared without my written consent, except as required by law.
I understand Cancellations with less than 24 hours’ notice, or missed appointments (no-shows), will be charged the full session fee.
I understand that massage involves touch. I give consent to receive massage therapy from the therapist at Listen to Your Body, and understand that I can withdraw consent at any time.
Your Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
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