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| Address Street 1: |
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| Address Street 2: |
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| Evening Phone: |
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| Date of Birth: |
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| Emergency Contact: |
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Emergency
Contact Phone: |
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How did you
hear about us? |
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Please Use Chart Above To List Corresponding Number(s) Associted With Pain, Discomfort and Areas of Concern Below With Explanations. |
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Y/N
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Please Mark "Y" for Yes and "N" for No in the Corresponding boxes. |
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Have you ever had a professional massage? If yes, how often? |
| Explanation: |
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Are you pregnant? If yes, how far along are you? |
| Explanation: |
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Are you sensitive to touch/pressure in any area? (Ticklish)?
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| Explanation: |
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Are you allergic or sensitive to any oils (essential oils, nut oils, scents?) If yes, please list. |
| Explanation: |
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Were you referred by a health care provider? If so, please indicate by who and specialty. |
| Explanation: |
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Do you have any difficulty lying on your front, back or side? If so, please explain. |
| Explanation: |
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Do you have sensitive skin? |
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Do you sit for long hours at a workstation, computer or driving? If so, please explain. |
| Explanation: |
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Do you perform any repetitive movement in your work, sports or hobby? If so, please explain. |
| Explanation: |
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Do you experience stress in your work, family, or other aspect of your life? If so, explain how it has affected your health. |
| Explanation: |
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| List current medications and reason: |
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| List any supplements, herbs, and/or vitamins you are currently taking: |
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| Areas of Pain/Tension on a scale from 1 to 10 |
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| How did your symptoms begin and when did they start? |
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| What have you done for relief? |
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| Is this condition getting better/worse? |
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Medical Conditions - If you are currently affected or have experienced in the past - Please check the correspondening condition that applies to you. |
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AccidentsAllergiesAnemiaAnxietyArthritisAsthma/Breathing Problems |
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AtherosclerosisAthletes FootBladder ProblemsBlood Clot |
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Blood Pressure (High/Low)Bone/Joint DiseaseBowel Problems |
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Broken Bones/FracturesBruise EasilyCancer/TumorsCarpal Tunnel Syndrome |
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Chronic FatigueChronic PainCirculatory ProblemsContact Lenses |
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Contagious IllnessDepressionDiabetes I/IIDrug/Alcohol/Caffeine/Tobacco Use |
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EmphysemaEpilepsyFibromyalgiaGoutHeart ConditionHernia |
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Herpes/Cold SoresHospitalizationInjuriesIrritable Bowel Syndrome |
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Jaw Pain/TMJJoint Strain/SprainJoint SwellingKidney AilmentLupus |
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LymphedemaMigraines/HeadachesMultiple SclerosisNumbness/Tingling |
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Open Sores/WoundsOsteoporosisOvarian/Menstrual Problems |
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Phlebitis/Vericose VeinsPinched NervePregnantProstateShingles |
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Sinus ProblemsSkin Problems (Rash, Sunburn, etc.)Sleep Disorder |
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Spinal ProblemsStrokeSurgerySwollen GlandsTendonitis/Bursitis |
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Thrombosis/EmbolismUlcersVision ProblemsOther |
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If you checked any of the items above, please list and explain in detail: |
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I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical/mental health. I understand that a massage therapist cannot diagnose illness, disease, or any medical, physical, or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments that I have. I understand that massage therapy is a therapeutic health aide and is non-sexual. I understand that if the massage therapist starts a session late, they will make it up at the end of the session if possible, or will reduce the fee accordingly. I understand that if I arrive late, my session will end at the originally scheduled time that I cannot keep. I am aware that I may be charged the full fee for any missed sessions that I do not give 24-hour notice to cancel or reschedule. |
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Electronic Signature Agreement: This service is provided to eliminate unnecessary use of paper. By typing in your name in the signature field, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You consent to be legally bound by this Agreement's terms and conditions, acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and PureHealth4Life. You further agree that each use of your E-Signature in obtaining PureHealth4Life service constitutes your agreement to be bound by the terms and conditions of PureHealth4Life Polices, Procedures and Agreements as they exist on the date of your E-Signature. |
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I have received, acknowleged reading and filled out the information truthfully and to the best of my knowledge. |
| Signature: |
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| Email: |
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| Date: |
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