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					                                                                 Shamrock Therapeutics
                                                             Confidential Client Information

    Name                                                                                                           Date
                             Last            First                                    MI                                    MM/DD/YY

    Address

                             Street                  Appt#                            City              State             Zip

    Home Phone                                       Work Phone                                         Email


                                                                                                        RECEIVE SPECIAL OFFERS. Your email address
                                                                                                        will not be sold or distributed to any outside
                                                                                                        agencies.
    Date of Birth                                                        Emergency Contact

    Occupation                                                                               Referred By

    Have you had a massage before?                       __YES         Are you               __YES __NO         Do you exercise        __YES   __NO
I   If so when was your last one?                        __NO          pregnant? If                             regularly?
                                                                       so, how many
                                                                       months?

     Please check any of the following that apply to you now or in the past:

      __Arthritis                            __Heart Attack/Stroke             __Fibromyalgia                         __Hypo or Hyperglycemia

      __High blood pressure                  __Muscle Strain/sprain            __Surgeries (in the past 2 years)      __Broken bones

      __Low blood pressure                   __Cancer                          __Contagious Conditions                __Skin Infections
      __Epilepsy                             __Migraines                       __Allergies                            __Skin problems
      __Diabetes                             __Spinal Injury                   __Varicose Veins                       __Blood Clots

Reason for visit:                      __Stress relief            __Pain relief              __Both stress AND pain relief

If you are here for PAIN RELIEF, please answer the following questions:
Where is the pain?                                                                      Have you had a doctor diagnose          __Yes __No
                                                                                        the pain?
How long have you had the pain?                                                         Is the pain dull or sharp?

Was there an incident that you believe caused                                           Does the pain fluctuate in              __Yes __No
the pain?                                                                               intensity from day to day or hour
                                                                                        to hour?
Does the pain radiate, if so, where?                                                    Does moving a certain way or            __Yes __No
                                                                                        being in a certain position
                                                                                        aggravate the pain?
Do you have numbness, tingling, zapping or                                              Does the pain increase with stress      __Yes __No
burning sensations?                                                                     levels?
What have you been doing on your own to ease
the pain?
Please circle a number to indicate your level of pain:
  0         1            2             3               4            5            6              7                8                  9          10
Pain    Very         Minor         Annoying       Can be         Can't be   Can't be       Makes it       Physical activity   Unable to        Unconscious.
free    minor        annoyance -   enough to      ignored if     ignored    ignored for    difficult to   severely limited.   speak.           You wouldn’t be
        annoyance    occasional    be             you are        for more   any length     concentrate,   You can read        Crying out       filling in this form!
        -            strong        distracting.   really         than 30    of time, but   interferes     and converse        or moaning
        occasional   twinges.                     involved in    minutes.   you can        with sleep     with effort.        Uncontrollably
        minor                                     your work,                still go to    You can        Nausea and           - Near
        twinges.                                  but still                 work and       still          dizziness set in    delirium.
                                                  distracting.              participate    function       as factors of
                                                                            in social      with effort    pain.
                                                                            activities.




 If you are here for STRESS RELIEF , please answer the following:
   How many hours a week do you work?                     Have you had any major changes in your life lately?                           YES____ No____

   Are you sleeping well? YES___ NO___


   Other medical conditions not already indicated:_______________________________________

   RELEASE
   Please read carefully and sign below:

           I am free of communicable diseases
           Proper draping (covering of the body with a sheet) will be used. There will be no deviation
            from it.
           I understand massage or bodywork should not be construed as a substitute for medical
            examination, diagnoses or treatment and that I should see a physician or other qualified
            medical specialist for any mental or physical ailment.
           I understand that massage therapists are not qualified to perform spinal or skeletal
            adjustments.
           I have stated all my medical conditions and answered all questions honestly.
           I agree to keep the therapist updated as to any changed in my medical profile and
            understand that there shall be no liability on the therapist’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.


 Signature____________________________________                               Date:________________

 For office use                     FUE              FUP             CC
 only

				
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