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 of Birth____________________________________________________________________
City__________________________________ State_________ Zip Code______________
Phone (Home)_____________________________ (Cell)______________________________
In case of emergency call ___________________________ Phone_____________________
Do you have any muscle pain, stiffness, or tension YES ___ NO____
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________________________________________
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.
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 _______________________