Date Of Appointment (Month/Date/Year) Full Name Date of Birth (Month/Date/Year) Address City State Zip Email Home Phone Work Phone Gender: - Select - male Female Occupation Emergency Contact Phone Relation Pls select your preferred method of communication for future appointment confirmation: - Select - Phone Call Email Text Are you under 18 years of age? - Select - Yes No Have you ever been diagnosed with cancer? If so. What type? If answered yes, when was your last cancer treatment? Do you have physician approval? - Select - Yes No Are you pregnant? If so, return to the front desk for a prenatal massage form. - Select - Yes No Do you have highblood pressure? - Select - Yes No On medication for blood pressure? - Select - Yes No Do you have any other medical condition? - Select - Yes No If yes, what type? Do you have any skin conditions such as athlete’s foot, warts, psoriasis, etc? - Select - Yes No Athlete’s foot - Select - Yes No Warts - Select - Yes No Psoriasis - Select - Yes No Others Do you have any allergies such as to nuts, oils, fragrances, etc? - Select - Yes No Have you been in accident or suffered any injuries in the past two years? - Select - Yes No Do you have cardiac or circulatory problem? - Select - Yes No Do you have diabetes? - Select - Yes No Do you suffer from epilepsy or seizures? - Select - Yes No Do you have a contagious disease? - Select - Yes No Are you sensitive to touch or pressure in any area? - Select - Yes No I am aware that the following symptoms are recognized as higher risk and compromised health issues. Heart disease Diabetes Age >62 Smoker Asthma Hence, I am giving my full consent to receive the massage. You must agree before submitting. I understand that the massage/bodywork is provided for relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner. Massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician. Chiropractor or other qualified medical specialist for any mental or physical ailment. Massage/bodywork practitioner are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. Because massage/bodywork should not be performed under certain medical conditions. I affirmed that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to my medical profile. Any illicit or sexually suggestive remarks or advances made by me will result in the termination of the session, and I will be liable for the payment of the scheduled appointment. You must agree before submitting. Electronic Aknowledgement Date Today (Month/Date/Year)
