Please print and bring to
your first appointment. Write clearly . Thank you
Healing Horizons
Massage
Therapy
Today's Date_____________DOB__________
First Name______________ Last
Name_______________
Address______________________City_______________
ST_____ Zip__________
Email(please
provide):____________________
Home Ph#____________Day
Work:______________
Cell_________________
How often do you use
the phone or computer ? (circle)
everyday,
sometimes, never , a few hours.
Marital
Status________ Referred by: _________________google ,Citysearch, yahoo.local, other________
Have you ever
received a professional massage
before?
Y
or N How long ago?
_______________
Do you
have any pain? Y or No Explain:
____________________________________________________
Do you
have any of the following ?
Y
N Do you suffer from
Stress?
Y
N Are you pregnant? How
many months?______
Y
N Do you have
Diabetes?
Y
N Do you experience
headaches?
Y N Do you Smoke?
Y
N Do you have
arthritis?
Y
N Do you bruise
easily?
Y
N Do you drink water
regularly?
Y
N Do you take vitamins
supplements?
Y
N Do you have high blood
pressure?
Y
N Do you suffer from seizures or
epilepsy?
Y
N Do you have joint
swelling?
Y
N Do you have
osteoporosis?
Y
N Do you suffer from back
pain
Y
N Do you have cardiac
problems?
Y
N Do you have numbness or
tingling
anywhere?____________
Y
N Are you sensitive to touch or
pressure?
Where?
______________________
Y
N Do candles or scented lotions bother you
?
Y
N Do you have any other medical any other
medical Condition I need to be aware of?
_______________
Y
N Have you broken any bones?
Y
N Have you been in accident or
suffered any injuries in past two years?
Where?________________________
I understand that
massage 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 inform the therapist so that
pressure or strokes may be adjusted to level of comfort. I
understand that massage should not be construed as a substitute for
medical treatment and that I should see a physician, chiropractor
or other qualified medical specialist. I also understand that any
illicit or sexually remarks or advances made will result in
immediate termination of the session, and I will be liable for
payment of the appointment.
Signature___________________________
Date______________
Consent to Treat a
minor: By signing below I herby authorize massage.
Signature of parent
or Guardian___________________ Date ___________
