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Client Information
Reason for Today's Visit
Areas of Pain / Discomfort
Mark all areas of pain or discomfort directly on the figures below. On a touchscreen, draw with your finger or a stylus; on a computer, click and drag with the mouse. Drawing is optional — if you cannot or prefer not to use the diagram, describe the locations in writing instead.
Brush
FRONT
LEFT SIDE
BACK
RIGHT SIDE
Medical Background
Health History
Mark Yes or No for each. For any “Yes,” add dates, medications, and details in the section below.
Acute systemic or localized infection / cellulitis
Epilepsy
Cancer / malignancy / treatment
Osteoporosis
Osteoarthritis / rheumatoid arthritis
Spinal problems / acute spinal disc herniation
Healing fracture / broken bones / open wounds
Cardiac or circulatory problems
High blood pressure
Blood clots
Obstructive edema
Anticoagulant therapy
Advanced diabetes
Currently pregnant
Frequent stress
Frequent headaches
Exercise regularly
Dentures
Skin problems / allergies
Cancellation Policy
The full rate applies to any appointment missed or cancelled with less than 24 hours’ notice.
Informed Consent
If you have a specific medical condition or symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required before services are provided.
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so the pressure and/or strokes can be adjusted to my level of comfort.
I understand that massage/bodywork is not a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, chiropractor, or other qualified specialist for any mental or physical ailment I am aware of. I understand that the practitioner is not qualified to perform spinal adjustments or to diagnose, prescribe for, or treat any physical or mental illness, and that nothing said in the session 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 regarding any changes to my health, and understand the practitioner shall not be liable should I fail to do so.
I understand that any inappropriate or sexually suggestive remarks or advances made by me will result in the immediate termination of the session, and I will remain responsible for payment for the scheduled appointment.
Complete the form, mark the figures if applicable, and then select Download PDF to save a completed copy.
