Therapeutic Massage by Nancy Hudspeth
Relaxing Therapy for the Mind, Body & Soul

Client Health History Form

 

   

  

Practitioner/Clinic Name: ____________________ Contact Information: ________________________

Client Contact Information

Health Information

(page 1 of 2)

Client Name: ___________________________________ Date of Birth: ____________Gender: ____________ Address: _________________________________________________________________________________ Phone: _______________________________________Email: ___________________________________ Referred by: ___________________________________ Emergency contact: _____________________________Phone: ___________________________________ Physician/Health-care Provider name: __________________________Phone: ____________________ Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?Yes No Do you have a physician referral/prescription?Yes No Are you seeking insurance reimbursement?Yes No If yes, please complete the Billing Information form. Type of insurance coverage for this claim: Car CollisionWorker’s CompensationPrivate Health

Massage Information

Date: ____________

Have you ever received professional massage/bodywork before?Yes No How recently? ___________________________________ What types of massage/bodywork do you prefer? ___________________________________ What kind of pressure do you prefer?LightMediumFirm What are your goals/expected outcomes for receiving massage/bodywork? _________________________________________________________________________________________ _________________________________________________________________________________________

How do you feel today? ______________________________________________________________________

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.): ______________________________________________________________________________________________ ______________________________________________________________________________________________

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No Explain: ______________________________________________________________________________________________ ______________________________________________________________________________________________

List the medications you currently take: ______________________________________________________________________________________________ ______________________________________________________________________________________________

Are you wearing contacts? Are you wearing dentures? Are you wearing a hairpiece? Are you pregnant?

 

   

Yes No Yes No Yes No Yes No

MEMBER

Associated Bodywork & Massage Professionals

   

  

Practitioner/Clinic Name: ____________________Health Information

Contact Information: ________________________

Health History

(page 2 of 2)

Have you had any injuries or surgeries in the past that may influence today’s treatment? ______________________________________________________________________________________________ Circle any of the following health conditions that you currently have (If you are unsure, please ask): blood clots, infections, congestive heart failure, contagious diseases, pitted edema Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast CurrentPast

Muscle or joint pain_____________________________________ Muscle or joint stiffness _____________________________________ Numbness or tingling _____________________________________ Swelling _____________________________________

Bruise easily _____________________________________ Sensitive to touch/pressure _____________________________________ High/Low blood pressure _____________________________________ Stroke, heart attack _____________________________________ Varicose veins _____________________________________ Shortness of breath, asthma _____________________________________ Cancer _____________________________________ Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________ Epilepsy, seizures _____________________________________ Headaches, Migraines _____________________________________ Dizziness, ringing in the ears _____________________________________ Digestive conditions (e.g. Crohn’s, IBS) _____________________________________ Gas, bloating, constipation _____________________________________ Kidney disease, infection _____________________________________ Arthritis (rheumatoid, osteoarthritis) _____________________________________ Osteoporosis, degenerative spine/disk _____________________________________ Scoliosis _____________________________________ Broken bones _____________________________________ Allergies _____________________________________ Diabetes _____________________________________ Endocrine/thyroid conditions _____________________________________ Depression, anxiety _____________________________________ Memory Loss, confusion, easily overwhelmed _____________________________________

Comments: ______________________________________________________________________________________________ ______________________________________________________________________________________________

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that 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 of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given 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 as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand 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 of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature: _____________________________________________________________ Parent or Guardian Signature (in case of a minor): ___________________________________

Date: ____________ Date: ____________