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#____________
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 tinglinganywhere?____________
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 ___________
