Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Physician
Emergency Contact
*
Leisure Activities/Exercise
How did you hear about me?
Last professional massage?
Do you have any medical conditions?
List Medications
Describe your reason for this visit and any conditions that may be causing discomfort
Have you had any injuries, surgeries in the past that may be related to your discomfort in any way? If so, list
Are their any areas that you feel uncomfortable receiving massage i.e.-abdominals, glutes, feet?
Any that you really want addressed?
Any other concerns related to the session?
What is your pressure preference?
Light
Medium
Firm
Deep
Is there anything else affecting your well-being? i.e. – work, stress, grief, movement patterns, etc…
Are you pregnant?
Are you wearing contacts?
Are you wearing dentures?
Health history. Give details of locations, past, current and/or anything else relevant
Numbness or tingling
Swelling
Bruise easily?
Communicable diseases
High/Low blood pressure
Diabetes
Stroke/Heart Attack
Varicose veins, if so where(not spider veins)?
Cancer
Epilepsy, Seizures
Headaches, Migraines
Digestive conditions
Arthritis
Osteoporosis, Degenerative disk etc…
Scoliosis
Broken bones… Previous and/or current
Allergies
Depression/Anxiety
Comments
If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my comfort level. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal adjustments, diagnose, prescribe or treat any physical or mental illness. Because, massage should not be performed under certain medical conditions, I that I have stated all of 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 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.*
Date
MM
DD
YYYY
Parent or Guardian Signature (in case of minor)
Date
MM
DD
YYYY
Thank You!
Detailed directions from RxR tracks to 318 Fountain Way Swannanoa, NC 28778:
Take 1st Rd after going under the bridge. Turn right onto 3rd Rd. Go up the hill, pass the church and look for the line of 4 mailboxes on the right. 318 is on a wooden sign at the end of the mailboxes. Turn right into my driveway here. My home office is not visible from the road. Park straight ahead and come to the side door entrance with small porch.
