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IName_________________________________________ Date______________ Referred by____________________
Address_____________________________________________ Phone day______________ Cell_______________City/State/Zip________________________________________ E-mail addre ______________________________Occupation__________________________________________ Date of Birth ______________ Male ( ) Female ( )Primary Health Care Provider__________________________________________ Phone ______________________Emergency contact __________________________________________________ Phone______________________Are you currently seeing a medical practitioner? ( ) Yes ( ) NoIf yes, please explain ____________________________________________________________________________List current medications, including aspirin, ibuprofen, etc. _______________________________________________ Please check the following items that apply to you, past & present: Muscular-skeletal Circulatory/ Respiratory Nervous System Other( ) Bone or joint disease ( ) Heart condition ( ) Numbness/ Tingling ( ) Depression( ) Tendonitis / Bursitis ( ) Varicose veins ( ) Chronic Pain ( ) Cancer/ Tumor( ) Arthritis ( ) Blood clots ( ) Fatigue ( ) Diabetes( ) Back/Hip pain ( ) High/Low blood pressure ( ) Sleep disorders ( ) Eating disorders( ) Leg/ Foot pain ( ) Dizziness ( ) Ulcers ( ) Nut Allergy( ) Neck/ Shoulder pain ( ) Shortness of breath ( ) Other ( ) Arm/ Hand pain ( ) Cold feet/ hands Skin( ) Headaches/ Head injuries ( ) Cold Sweats Reproductive ( ) Allergies( ) Stiffness/ Swelling ( ) Allergies ( ) PMS ( ) Rashes( ) Spasms/ Cramps ( ) Sinus problems ( ) Pregnant? ( ) Athlete’s Foot( ) Sprains/ Strains ( ) Asthma ( ) Other ( ) Other( ) Broken/ Fractured bones ( ) Lymph edema ( ) Fibromyalgia ( ) Stroke ( ) Other: ( ) Other: List any surgeries you have had:___________________________________________________________ PLEASE READ THE FOLLOWING WAIVER. ACKNOWLEDGE YOUR UNDERSTANDING & AGREEMENT BY SIGNING BELOW. Because a Massage Therapist must be aware of any existing physical condition I may have, I have listed all my medical conditions and I will inform my therapist of any changes in my health. I understand that Massage Practitioners do not diagnose illness, disease, or any physical/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 I see a primary health care provider for that service. I understand that my session(s) are strictly ethical and therapeutic. Forward or sexual behavior will not be permitted, if so my session will be discontinued at that time. I agree to communicate with my therapist any time I feel my wellbeing is being compromised. Signature: Date:'m a paragraph. Click here to add your own text and edit me. I’m a great place for you to tell a story and let your users know a little more about you.