Ashland Massage Therapy by Beka Chandler Injury Specialist

MEDICAL HISTORY QUESTIONNAIRE

The purpose of this confidential form is to maximize the safety and effectiveness of your massage.

Date___________________________________________________________________________

Referred by_____________________________________________________________________

Name__________________________________________________________________________

Date of Birth____________________________________________________________________

Address________________________________________________________________________

City__________________________________       State_________       Zip Code______________

Phone (Home)_____________________________       (Cell)______________________________

Email address___________________________________________________________________

In case of emergency call ___________________________       Phone_____________________

Do you have any muscle pain, stiffness, or tension       YES ___       NO____
            Where____________________________________________________________________

Is there any area where you would like extra time spent?       YES ___       NO____
            (neck, shoulders, low back….)_________________________________________________

Do you have trouble sleeping?       YES ___       NO____

Are you pregnant?       YES ___       NO____       Due _______________

Please Indicate and List Any Medical Problems or Conditions

Blood Pressure, Diabetes, Gout, Cancer other________________________________________

Current Medications______________________________________________________________

Do you have a Nut Allergy?       YES ___       NO____

Skin Conditions – acne, rash, allergies, skin cancer, other______________________________

Lymphatic condition – swollen glands, lymphoma, other_______________________________

Recent Injury – whiplash, sprain, bruise, other________________________________________

Circulatory condition – heart disease, varicose veins, phlebitis, arteriosclerosis, other

_______________________________________________________________________________

Neurological condition – sciatica, numbness/tingling, stroke, epilepsy, other

_______________________________________________________________________________

Joint problems, pain or stiffness – osteoarthritis, rheumatoid arthritis

_______________________________________________________________________________

Bone Conditions – osteoporosis, previous fractures, cancer, other

_______________________________________________________________________________

Headaches – migraines, PMS, tension, sinus, other

_______________________________________________________________________________

Emotional difficulties – depression, anxiety, psychotic episodes, other

_______________________________________________________________________________

Stress       YES ___       NO____

Recent surgery (type and date)_____________________________________________________

Are you under a Doctor’s care?       YES ___       NO____       Phone_______________________

You have my permission to contact my health care provider(s)_________(initial)

CANCELLATION & LATE  POLICY

 If the client cancels their appointment with less than a 24-hour notice,  or does not show for an appt, a cancellation fee of 50%- up to full scheduled session fee will be paid by the client.

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscle tension. If I experience any pain, discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.  I further understand the massage or bodywork should not e 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 of which I am aware.  I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical mental illness, and nothing said in the course of the session given should be construed as such. Because massage/bodywork 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 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 also understand that any illicit or sexually suggestive remarks or advances made by the client will result in immediate termination of the session, and I will be liable for payment of the scheduled session.  If a client arrives late to their appointment, there will be no cost adjustment and will end at the scheduled time as to not delay the next appointment.

Signature________________________________________ Date____________________

Consent for a minor By my signature below, I hereby authorize Andrea Carangelo, CMT to administer massage bodywork to my child or dependent, as they deemed necessary.

Signature of Parent Guardian_______________________________ Date _______________________