Practitioner/Clinic Name: ____________________ Contact Information: ________________________
Client Contact Information
Health Information
(page 1 of 2)
Client Name: ___________________________________ Date of Birth: ____________Gender: ____________ Address: _________________________________________________________________________________ Phone: _______________________________________Email: ___________________________________ Referred by: ___________________________________ Emergency contact: _____________________________Phone: ___________________________________ Physician/Health-care Provider name: __________________________Phone: ____________________ Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?Yes ☐ No ☐ Do you have a physician referral/prescription?Yes ☐ No ☐ Are you seeking insurance reimbursement?Yes ☐ No ☐If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car CollisionWorker’s CompensationPrivate Health
Massage Information
Date: ____________
Have you ever received professional massage/bodywork before?Yes ☐ No ☐ How recently? ___________________________________ What types of massage/bodywork do you prefer? ___________________________________ What kind of pressure do you prefer?LightMediumFirm What are your goals/expected outcomes for receiving massage/bodywork? _________________________________________________________________________________________ _________________________________________________________________________________________
How do you feel today? ______________________________________________________________________
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.): ______________________________________________________________________________________________ ______________________________________________________________________________________________
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No Explain: ______________________________________________________________________________________________ ______________________________________________________________________________________________
List the medications you currently take: ______________________________________________________________________________________________ ______________________________________________________________________________________________
Are you wearing contacts? Are you wearing dentures? Are you wearing a hairpiece? Are you pregnant?
Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐
MEMBER
Associated Bodywork & Massage Professionals
Practitioner/Clinic Name: ____________________Health Information
Contact Information: ________________________
Health History
(page 2 of 2)
Have you had any injuries or surgeries in the past that may influence today’s treatment? ______________________________________________________________________________________________ Circle any of the following health conditions that you currently have (If you are unsure, please ask): blood clots, infections, congestive heart failure, contagious diseases, pitted edema Please answer honestly, as massage may not be indicated for the above conditions.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:
CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast
Muscle or joint pain_____________________________________ Muscle or joint stiffness _____________________________________ Numbness or tingling _____________________________________ Swelling _____________________________________
Bruise easily _____________________________________ Sensitive to touch/pressure _____________________________________ High/Low blood pressure _____________________________________ Stroke, heart attack _____________________________________ Varicose veins _____________________________________ Shortness of breath, asthma _____________________________________ Cancer _____________________________________ Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________ Epilepsy, seizures _____________________________________ Headaches, Migraines _____________________________________ Dizziness, ringing in the ears _____________________________________ Digestive conditions (e.g. Crohn’s, IBS) _____________________________________ Gas, bloating, constipation _____________________________________ Kidney disease, infection _____________________________________ Arthritis (rheumatoid, osteoarthritis) _____________________________________ Osteoporosis, degenerative spine/disk _____________________________________ Scoliosis _____________________________________ Broken bones _____________________________________ Allergies _____________________________________ Diabetes _____________________________________ Endocrine/thyroid conditions _____________________________________ Depression, anxiety _____________________________________ Memory Loss, confusion, easily overwhelmed _____________________________________
Comments: ______________________________________________________________________________________________ ______________________________________________________________________________________________
Consent for Treatment
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.
Client Signature: _____________________________________________________________ Parent or Guardian Signature (in case of a minor): ___________________________________
Date: ____________ Date: ____________
