Massage Therapy Client Consultation FormYour personal information is completely confidential. Please fill out the entire form to the best of your ability. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email What is your gender? Date of Birth * MM DD YYYY Emergency Contact * Emergency Contact Phone Number * (###) ### #### Health Information Please check all that apply. Cardiovascular * Heart Conditions Vascular Disorder Low blood pressure High blood pressure Circulatory problems None Head/Neck/Back * Sinus problems Headaches/Migraines Epilepsy Scoliosis TMJ Disorder None Muscle/Joint * Arthritis Fracture/Dislocation Fibromyalgia Metallic implants Osteoporosis Carpal Tunnel Syndrome Tennis Elbow None Respiratory * Asthma Smoker None Other * Pregnant Hormonal changes Thyroid condition Psoriasis Cancer Lymphatic disorders Bruising Diabetes Claustrophobia TB, HIV, Hepatitis, etc. Numbness Infectious conditions None Any other conditions not mentioned above. * Are you currently under medical supervision? * Yes No Do you have any allergies to oils, lotions, or ointments? * Yes No Do you have any other allergies? (i.e. aspirin, dairy, etc.) * Yes No Are you currently taking ANY medications? (i.e. birth control, blood thinners, etc.) * Yes No How did you hear about Makana Massage? * Have you had a professional massage before? * Yes No What are your expectations for this visit? * Check all that apply. Prevention Pain Management Relaxation Other Do you have any difficulty lying on your front, back, or side? * Yes No Do you sit for long hours at a workstation, computer, or driving? * Yes No Do you perform any repetitive movement in your work, sports, or hobby? * Yes No Have you had surgery? * Yes No Is there a particular area of the body where you are experiencing tension, stiffness, pain, or other discomfort? * Do you have areas in which you would like to focus? Preferred massage pressure? * Firm Medium Light Draping will be used during the entire session - only the area worked will be uncovered. Clients under the age of 18 must be accompanied by a parent or legal guardian, and informed consent must be provided. Makana massage reserves the right to refuse service to anyone. I understand that the treatment(s) I receive are provided for the basic purpose of relaxation and relief of muscular tension. If I experience any discomfort during my treatment(s), I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that the treatment(s) 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 that I am aware of. I understand that therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said within the course of the treatment(s) should be construed as such. Because some treatments 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the business and therapist's part should I fail to do so. 24 hour notice required to cancel appointments to avoid a no show fee. No show fees are the full price of the scheduled session. I affirm that I have read the above statements and understand that by printing my name below, I am signing this document. * Date * MM DD YYYY Thank you!
