Goble Heal Chiropractic Massage Intake Form (Page 2 of 2) in pdf

Please check any condition listed below that applies to you:

( ) contagious skin condition

( ) phlebitis

( ) open sores or wounds

( ) deep vein thrombosis/blood clots

( ) easy bruising

( ) joint disorder/rheumatoid

( ) recent accident or injury

( ) arthritis/osteoarthritis/tendonitis

( ) recent fracture

( ) osteoporosis

( ) recent surgery

( ) headaches/migraines

( ) artificial joint

( ) cancer

( ) sprains/strains

( ) diabetes

( ) current fever

( ) decreased sensation

( ) swollen glands

( ) back/neck problems

( ) allergies/sensitivity

( ) fibromyalgia

( ) heart condition

( ) TMJ

( ) high or low blood pressure

( ) carpal tunnel syndrome

( ) circulatory disorder

( ) tennis elbow

( ) varicose veins

( ) pregnancy If yes, how many months

( ) atherosclerosis

( ) epilepsy

Please explain any condition that you have marked above

___________________________________________________________________________________

Is there anything else about your health history that you think would be useful for your massage practitioner

to know to plan a safe and effective massage session for you?

_______________________________________________________________________________________

Draping will be used during the session- only the area being worked on will be uncovered. Clients under the

age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written

consent must be provided by parent or legal guardian for any client under the age of 17.

I, ______________________________ (print name) understand that the massage I receive is provided for

the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during

this session, 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 massage 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 massage therapists

are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or

mental illness, and that nothing said in the course of the session given should be construed as such. Because

massage 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 therapist’s part should I

fail to do so.

Signature of client ___________________________________ Date _____________________

Options

□ 15 minute chair massage

Neuro-muscular massage

30 minute relaxation

□ 30 minute deep tissue

60 minute relaxation

60 minute deep tissue

□ 90 minute therapeutic

Hot stone 90 minute therapeutic

Detox massage

Goble Heal Chiropractic Massage Intake Form Page 2

Related Articles

Related forms

Related Categories