MH FITNESS + HEALTH MASSAGE FORM

MH FITNESS + HEALTH

MASSAGE HEALTH FORM
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Emergency Contact*

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What are your current ailments?
What type of pain are you currently experiencing?

Stabbing PainElectrical Pain (Sharp Electric Shock)Burning PainAchy PainWidespread Pain & TendernessMuscle SpasmsTension PainSharp Pain, Localised, Small AreaNoneOther
How did your issue/pain begin?

SlowlySuddenlyIt has gotten worse over time.It has improved over time.I'm not sure how it happened or how it progressed.N/A I do not have an issue or pain.Other
Please list all surgeries:
HEAD INJURY: Please list any significant head injuries, such as concussions, being knocked unconscious, or traumatic brain injury.
BODY INJURY: Please list any significant injuries to your joints, muscles, or bones.
Do you have any special needs I should prepare for?
List all medication prescription & non prescription (if any)
Are you currently pregnant?*
Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Matt Hobson to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History*

	Current	Past	Never
Pregnancy
Blood Clots*
Congestive Heart Failure*
Unexplained Calf Pain
Varicose Veins*
Stroke or Heart Attack*
Cancer*
Car Accident*
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Osteoporosis
Broken Bone
Allergies that Require an Epi-Pen
Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance*
Endocrine / Thyroid Condition*
Chronic Depression
Chronic Anxiety
Chronic Swelling
Sensitive to Touch / Pressure*
Easy Bruising*
Shortness of Breath / Asthma
Chronic Muscle / Joint Stiffness
Chronic Muscle / Joint Pain
Chronic Pain*
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash*
Fibromyalgia*
Multiple Sclerosis
Memory Loss / Confusion

Cancellation Policies

100% Full Payment is required for the following conditions:
- No Show: If you do not show up for an appointment, you will be charged the full cost for the appointment. Payment is due before your next appointment.
- Late Arrival: If you are late to your session you are welcome to receive whatever time is left in your appointment. Due to our tightly booked schedule we are generally unable to extend your session beyond your original appointment time. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled. Please plan to arrive 10 minutes early for your appointment.
50% Payment is required for the following condition:
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 100% of the scheduled appointment fee. Payment is due before your next appointment.
Sickness Policy

Please reschedule your appointment as soon as you are aware of an infectious or contagious condition.

If you arrive for your appointment with symptoms of an illness, you will kindly be asked to reschedule your appointment to avoid the spread of germs. This protects are most susceptible loved ones - children, the elderly, & people with suppressed immune systems, like cancer patients.

If any of the following describes you, I kindly ask that you reschedule your appointment so we can prevent the spread of bugs:
- Fever or Chills
- COVID-19 symptoms
- Vomiting or Diarrhea
- Runny Nose
- Sore Throat or Cough
- You are currently taking an antibiotic.
- You have a skin infection like ringworm or athletes foot.
- You or someone in your direct care has a cold, sinus infection, or flu bug.
- You or someone in your direct care has been diagnosed with influenza (the flu).
Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing.
Informed Consent
Cancellation Policies

100% Full Payment is required for the following conditions:
- No Show: If you do not show up for an appointment, you will be charged the full cost for the appointment. Payment is due before your next appointment.
- Late Arrival: If you are late to your session you are welcome to receive whatever time is left in your appointment. Due to our tightly booked schedule we are generally unable to extend your session beyond your original appointment time. Regardless of the length of the service actually given, you will be responsible for payment of the full service you scheduled. Please plan to arrive 10 minutes early for your appointment.
50% Payment is required for the following condition:
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24 hours in advance will result in a charge of 100% of the scheduled appointment fee. Payment is due before your next appointment.
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