Name
|
Date
|
Address
|
Phone number(s)
|
Birthdate
|
Occupation
|
Email address
|
Have you ever had a massage before?
No
Yes
When and type of massage experienced :
|
What results would you like to see from your
sessions?
|
| Are there any areas of your body you would like
to focus on or prefer be avoided?
|
Please include the names of any healthcare
professionals you are currently seeing and reason/treatment.
|
| Do I have permission to contact them concerning
your current condition, if I feel that it is necessary for your safety?
Yes
No
Only with my express consent, on a per-incident basis. |
Are you currently taking any medications/supplements/herbs/homeopathic
remedies?
No
Yes Which?
|
Please review this list and check those conditions that have affected
your health either recently or in the past.
(*AIDS, fibromyalgia, chronic fatigue, lupus, etc.) |
Do you have any of the following today?:
skin rash
cold/flu
open cuts
severe pain
anything contagious
injuries/bruises |
Do you have any allergies to:
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)
reactions to skin care products
If any of the above are checked, please give details:
|
All massage received will be therapeutic wellness massage, to promote
relaxation and relieve discomfort caused by tension. I declare that,
to the best of my knowledge, the above information is accurate and truthful.
According to informed consent, I acknowledge that I am aware of the
minor potential for soreness, bruising, or headaches in the days following
a therapeutic massage. I also acknowledge that I am aware that any massage
received will be non-sexual in nature. If, at any time, either client
or therapist feels uncomfortable with the situation, the session may
be terminated immediately. |
|
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