Massage Intake by peirongw


									A Woman’s Touch Plastic Surgery Center
MASSAGE Date of scheduled massage appointment:

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Client Information Name: Address: Phone numbers Home: Work: Cell: Email*: Occupation:

Health History

Have you ever received massage therapy? Type of massage experienced? (Swedish, deep tissue shiatsu, etc.) Are there any areas that should be avoided during the massage?

Are you wearing: Please list current medications /reasons for taking Are you currently under a physician’s care? If so, please describe reason/treatment.

contact lenses

hearing aid(s)


Please delete the  by any current or past conditions that have NOT affected your health.
Physical: Muscles, Bones and Joints  arthritis  broken/dislocated bones  bruise easily  chronic pain  TMJ disorder  muscle strain/sprain  scoliosis  whiplash  pins/joint replacement Systemic: Overall Health  diabetes  cancer  chronic pain  auto-immune condition  hepatitis (A, B, C, other)  pregnancy  seizures  allergies (list below) Circulatory: Heart, Lungs, Veins  blood clots  stroke  heart conditions  high blood pressure  low blood pressure  pacemaker Other (Please Specify)  skin conditions/rashes  surgery (describe below)  psych condition (panic disorder, depression, etc)  diverticulitis  headaches  insomnia  chemical dependency

If there are any other conditions your therapist should be informed of or anything above needs to be explained, please do so. Please indicate the areas , where you are having pain, discomfort, stiffness or limited range of motion, below:
Head top of head sides of head (L or R) back of head forehead Neck base of skull along vertebrae sides of neck & shoulders Shoulders, Arms & Hands around scapulae upper arm lower arm hands (L or R) Torso and Back chest ribs upper back mid-back lower back tailbone hips (L or R) gluteal muscles Legs & Feet thigh (front – quads) thigh (back-hamstrings) lower leg (front-shins) lower leg (back- calfs) ankles feet                                 

What are your goals/expectations for this therapy session? The following sometimes occurs during massage. They are normal responses to relaxation. -The need to move, stretch or change position - sighing, yawning, change in breathing - emotional feelings and memories -stomach gurgling or movement of intestinal gas -falling asleep Please read the following and type your initials below in lieu of a signature. 1) I understand that although massage can be very therapeutic, relaxing and can reduce muscular tension, it is not a substitute for medical examination, diagnosis, and/or treatment. 2) This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be responsible for payment of the session. 3) I understand that massage should not be done under certain medical conditions and I affirm that I have answered all questions pertaining to medical condition truthfully. Client’s initials: Date:

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