Sole Connection Theraputic & Prenatal Massage

SOLE CONNECTION CLIENT INTAKE AND HEALTH HISTORY FOR MASSAGE THERAPY

Name_________________________________________________________________  Date____________________
Address______________________________________________City_________________Province_______Postal Code_______
Date Of Birth____________________________  Occupation___________________________________________
Telephone (Home)____________________  (Work)______________________ (Cell)_______________________
E-Mail Address_______________________________  Preferred Means of Contact _________________________
Emergency Contact (Name/Phone No.)_____________________________________________________________
Referred By? _________________________________________________________________________________
1.  Are you currently under medical supervision?  Yes   No
      If yes, please explain_____________________________________________________________________
2.  Are you currently taking any prescription or herbal medication?  Yes   No
      If yes, please list___________________________________________________________________________
      Physician’s Name/Phone No._________________________________________________________________
      Permission to contact? (Signature Required)________________________________________________
3.  Please note level and type of your exercise or physical activity: _____________________________________
___________________________________________________________________________________________
4. Please check any condition below that applies to you:  (Elaborate as necessary)

___ Skin condition (eg, acne, rash, psoriasis, allergy, easy bruising, contagious condition)

___ Allergies (Note: ______________________________________________________)

___ Recent accident, injury, surgery (eg, whiplash, sprain, broken bone, deep bruise)

___ Muscular problem (eg, tension, cramping, chronic soreness, spasm, tremor)

___ Joint problem (eg, osteoarthritis, rheumatoid arthritis, dislocation, joint replacement)

___ Lymphatic condition (eg, swollen glands, lymphedema, lymphoma, nodes removed)

___ Circulatory conditions (eg, atherosclerosis, varicose veins, phlebitis, anemia)

___ Circulatory-Other (heart attack, arrhythmias, blood pressure concerns, hemophilia)

___ Neurologic (stroke, sciatica, epilepsy, multiple sclerosis, cerebral palsy, numbness)

___ Digestive (eg, ulcer, colitis, Crohn’s Disease, acid reflux, constipation, diarrhea)

___ Immune System (chronic fatigue, HIV/AIDS, other ______________________)

___ Skeletal System (osteoporosis, bone cancer, spinal injury, other ____________)

___ Endocrine (diabetes, other glandular disorders __________________________)

___ Headache (tension, migraine, cluster)

___ Cancer (currently, or previously _____________________________________)

___ Emotional (depression, anxiety, panic attacks, traumatic incidents, etc)

___ Prior surgery, disease, or condition that may be affecting you now

___ Cosmetic Surgery (Note: _______________________________________________)

___ Piercings (other than ears  Where?______________________________________________)

1. Have you had massage therapy before?    Yes     No   Type___________________________________________
2. Do you have any difficulty lying on your front, back, or side?   Yes   No
    If yes, please explain_________________________________________________________________________
3. Do you have allergic reactions to any oils, lotions, ointments, or other substances applied to your skin?   Yes   No  
    If yes, please identify and explain_______________________________________________________________
4. Do you wear            contact lenses (    )                        dentures (    )                        a hearing aid (    )?
5. Do you sit for long periods at a desk, computer, or driving?  Yes   No
    If yes, please explain__________________________________________________________________________
6. Do you stand in one place for long periods of time?   Yes      No
7. Do you perform any repetitive movements in your work, sports, or hobby?  Yes   No
    If yes, please explain__________________________________________________________________________
8.  Do you require assistance getting on or off the massage table?  Yes   No
9.  How would you describe your stress level?  Low    Medium    High     Extremely High
10.  Is there a particular area(s) of the body where you experience tension, stiffness, pain, or other discomfort?     Yes      No      If yes, please identify________________________________________________________________

Massage Therapy Informed Consent

I have read and understood this Client Intake and Health History form in its entirety.  If at any time there are changes in the information given, or in my condition, I will notify the therapist and update this form before receiving additional massage. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive massage, I am responsible for bringing that information to the therapists attention by noting it here:

_________________________________________________
     
The massage treatment I am requesting is for the purpose(s) of relaxation, stress reduction, relief from muscle tension or spasm, to improve range of motion, circulation, or energy, and to receive a positive experience of touch.

I understand the massage therapist does not diagnose or prescribe for medical illness, disease, or other disorders, and that spinal manipulations are not part of massage therapy. I further understand that massage therapy is not a substitute for medical examination or diagnosis, and that I take responsibility for consulting with my physician for any ailment or condition of concern to me.  If I experience any pain or discomfort during the massage session, I will immediately communicate that to the therapist so that treatment can be adjusted accordingly.

I understand that my therapist will be sure to respect my privacy during your session. The only area of my body that will be uncovered will be the area my therapist is working on at that time.

I understand that my feedback is an essential element in my treatment.  If at any time I become uncomfortable during the massage, I may bring that to the therapist’s attention and request that the session be modified, temporarily suspended, or brought to an end.  However, I can ask that a session be discontinued at any time, for any reason, and the therapist’s will honor that request.

I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so I have reviewed this form, and the information contained in my Client Intake and Health  History, with the massage therapist.  By my signature, I consent to receive massage therapy.

_______________________________________          ________________________
Client’s Signature                    Date

_______________________________________          ________________________
Massage Therapist’s Signature                                        Date

_______________________________________           _______________________
Parent’s signature if under 18                                          Date
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