Have you ever had a professional massage? YES___ NO ___ if yes, when ___________
Does any thing stand out in your mind about your previous massages? (Good or bad) ___________
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What results do you want from your massage sessions______________________________________
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Prioritize the areas of your body you would prefer to have massaged. __________________________
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Are there any areas of your body you do not give permission to have massaged?___________________
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Please list any current medication (include aspirin and Ibuprofen). Please include dosage and application.
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List your regular stress reduction, stretching and exercise activities. ___________________________
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Are you currently seeing a Medical Professional or Psychotherapist? NO_____ YES_______
Please explain_____________________________________________________________________
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List any surgeries, auto accidents, and major falls. (Please provide year and treatment received)
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Please mark any of the following that you have now or have had in the past. Please provide explanation if needed.
___ bone or joint disease _______________ ___ allergies __________________________________
___ tendonitis ________________________ ___ rashes ___________________________________
___ bursitis __________________________ ___ athletes foot ______________________________
___ broken bones _____________________ ___ constipation _______________________________
___ arthritis __________________________ ___ diverticulitis _______________________________
___ sprains / strains ____________________ ___ irritable bowel syndrome _____________________
___ Low back, hip, leg pain ______________ ___ herpes / shingles ___________________________
___ neck, shoulder, arm pain _____________ ___ numbness / tingling _________________________
___ headaches ________________________ ___ chronic pain _______________________________
___ spasms /cramps ____________________ ___ sleep disorders ____________________________
___ jaw pain/TMJ ______________________ ___ heart condition _____________________________
___ lupus____________________________ ___ blood clots ________________________________
___ high blood pressure_________________ ___ low blood pressure _________________________
___ lymphedema ______________________ ___ breathing difficulty __________________________
___ sinus problems ____________________ ___ cancer/tumors _____________________________
___ diabetes __________________________ ___ depression_________________________________
___ drug / alcohol addiction ______________ ___ HIV/AIDS__________________________________
___ infectious diseases __________________ ___ other _____________________________________
Women
___ Are you pregnant? NO___ YES ___ Stage ________________
If yes, history of miscarriage? YES___ NO____
___ Menopause ______________________ ___ Endometriosis / Fibroid Cysts__________________
It is my choice to receive massage therapy. I realize that the treatment is being given for the well being of my body and mind. This includes stress reduction, relief from muscular tension, spasm, pain, and for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel my well being is being compromised.
I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service.I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health.
Signature______________________________________________________
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