CLIENT INFORMATION

Name:  __________________________________    Date:  _____________________________

E-Mail:  _______________________________________________________________________ 

Date of Birth:  _________________   Referred By:  ___________________________________

Address:  _____________________________________________________________________

City:  ________________________________ State:  _________  Zip Code:  ______________

Home Phone:  _________________________  Cell Phone:  _____________________________

Occupation:  ___________________________________________________________________

Person to contact in case of an emergency/phone number:  _____________________________

Please circle any that apply:  Pain/Tightness in  SHOULDER:  RIGHT  LEFT

                                                Pain/Tightness in NECK:  RIGHT  LEFT

                                                Pain/Tightness in LOW BACK

                                                Pain/Tightness  ARM:  RIGHT  LEFT    LEGS:  RIGHT   LEFT

Please check if you have or have had any of the following:

AIDS/HIV_____      Epilepsy_____        Pacemaker _____      Parkinson's Disease _____

Migraine Headaches _____   Diverticulitis _____    Fractures _____      Anemia _____  

Athritis _____  Asthma _____  Bleeding Disorder _____     Cancer _____   Diabetes _____ 

Heart Disease _____  Hepatitis _____   Hernia _____   Herniated Disc _____   Herpes _____   

High Cholesterol _____  Kidney Disease _____   Liver Disease _____    Osteoperosis _____   

Pinched Nerve _____  Pneumonia _____  Varicose Veins _____    Siezures _____

Rheumatoid Arthritis _____   Stroke _____    Phlebitis _____    Plantar wart(s) _____  

Fibromyalgia _____   Fever _____   High Blood Pressure _____  Low Blood Pressure _____

Sciatica _____  Siezures _____  Skin Condition _____  Athlete's Foot _____  Headaches _____

Other _________________________________________________________________-

ALLERGIES

Please circle all allergies:

Almond    Camphor    Citrus    Coconut    Eucalyptus    Lanolin 

Lavender    Menthol    Nut Oils    Peppermind    Soy 

Other:  ____________________________________________________________________

Please describe any concerns and your objectives in seeking wellness

services here:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 Informed Consent

I hereby consent to my Therapist to provide me with massage therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended by my Therapist.

I acknowledge that the Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder.  I clearly understand that massage therapy is not a substitute for a medical examination.  It is recommended that I attend my personal physician for any ailments that I may be experiencing.  I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment.  I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.

I acknowledge and understand that the Therapist must be fully aware of my existing medical conditions.  I have completed my medical history form as provided by my Therapist and disclosed to the Therapist all of those medical conditions affecting me.  It is my responsibility to keep the Massage Therapist updated on my medical history.  The information I have provided is true and complete to the best of my knowledge.

I authorize my Therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third party payers.

I have read the above noted consent and I have had the opportunity to question the contents and my therapy.  By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my Therapist from time to time, to deal with my physical condition and for which I have sought treatment.  I understand that at any time I may withdraw my consent and treatment will be stopped. 

____________________________________                      __________________________

Signature of Client                                                   Date

_______________________________                        ______________________

Witness                                                                   Date