CLIENT INFORMATION ACKNOWLEDGEMENT & RELEASE
Name:______________________________________________________________________________________
Address:
_________________________________________________________
Phone:__________________________________
Date of Birth:
_________________________________
Referred
by:
_________________________________________-
In case of emergency: Name: _____________________________________________
Home phone:
______________________________
Work/Cell phone:
____________________
Email address:
_________________________________________
It is the client's sole responsibility to inform the practitioner of any
changes in the above.
GENERAL &
HEALTH-RELATED INFORMATION:
The information provided is voluntary on your part
It is not intended for disclosure or dissemination and
will be treated as confidential.
Reason for
your visit:
YES NO
_ Have you ever had a professional massage/bodywork session?
__
Do you
frequently suffer from stress? __
Do you
experience frequent headaches? _ __
Are you
pregnant? __
Do you wear contact lenses, acupuncture staples, prosthetic
limbs, __
Are you
diabetic? ____
Do you have high blood pressure?
__
Are you taking any medications?
__
Are you epileptic? __
Do you have trouble with varicose
veins or blood clots? ____
IF YOU ANSWER YES TO ANY QUESTION IN THIS SECTION, PLEASE
EXPLAIN AS CLEARLY AS POSSIBLE:
Have you ever had surgery? __ __
Have you had any broken bones in the past two years? __ __
Do you have cardiac or respiratory problems? _______
Do you
suffer from back pain? __________
Do you have any limitations of
mobility? _ _
Do you have any tension or
soreness in a specific area? ___
if yes to the above, is this discomfort recurring or chronic? ______
Do you have any numbness or
stabbing pains anywhere? ______
Are you very sensitive to touch/pressure in any
particular body area? ____
Do you have any other medical condition I should be aware
of? ____
Is there anything else you would like me to be aware of?
_____
Any questions that you answered affirmatively to will be discussed with
you prior to your session. Thank you!
It is the client's sole
responsibility to inform the practitioner of any changes in the client's
health-related profile.
Please take a moment to carefully read and understand the
following information. Please acknowledge and sign where indicated.
Name (please print) ________________________________________________________________
I understand that the
massage/bodywork I receive is provided for the basic purpose of relaxation,
stress reduction, and relief of muscular tension. If I experience any pain or
discomfort during the session, I will immediately and clearly inform the
practitioner so that the pressure and/or strokes may be adjusted to my
communicated level of comfort.
I understand that
massage/bodywork should not be construed as a substitute for medical
examination, diagnosis, or treatment, and that I should consult a physician,
chiropractor, or other qualified medical specialist for any mental or physical
ailment of which I am aware. I further understand that the practitioner is not
a 'provider of health care' for any purpose.
1 understand that massage tharapists/bodyworkers
are not qualified to perform spinal or skeletal adjustments, or diagnose,
prescribe or treat any physical or mental illness, and that nothing said in the
course of the session(s) should be construed as such.
I understand that
massage/bodywork is contraindicated (should not be done) under certain medical
conditions. Therefore, 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 as represented by
me, and understand that there shall be no liability on the practitioner's part
should I fail, for whatever reason, to do so.
It is also understood 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 for the 'full' scheduled appointment.
I understand that a 24-hour notice of
cancellation is required or I will be liable for full payment for the missed
appointment.
I further understand, acknowledge and certify that all the foregoing is
true to the best of my knowledge and belief, and that I presently have no
condition that would make this release anything other than knowing and
voluntary.
Signed: ________________________________Date: __________
Practitioner:
_____________________________Date: __________