Massage/body Treatment Consent Form printable pdf download

Massage/Body TreaTMenT ConsenT ForM

Name: ____________________________________________

GENERAL & MEDICAL INFORMATION

YES

____ ____ Have you ever had a professional massage/body treatment session?

____ ____ Do you frequently suffer from stress?

YES

____ ____ Are you pregnant?

____ ____ Do you frequently suffer headaches?

____ ____ Are you wearing contact lenses?

____ ____ Have you had broken bones in the past two years?

____ ____ Are you diabetic?

____ ____ Do you have tension or soreness in a specific area?

____ ____ Are you epileptic?

____ ____ Do you have cardiac or circulatory problems?

____ ____ Do you suffer from back pain?

____ ____ Are you very sensitive to touch/pressure in any area?

____ ____ Have you ever had surgery?

____ ____ Do you have numbness or stabbing pains anywhere?

____ ____ Do you have any other medical conditions we

____ ____ Do you have high blood pressure? If yes, list

should be aware of? _______________________

medications: __________________________________

_________________________________________

_____________________________________________

Comments: ____________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Please take a moment and carefully read the following information and sign where indicated.

If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider

may be required prior to services being provided. I understand that the massage/bodywork 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 should immediately inform the practitioner so that the pres-

sure and/or strokes may be adjusted to my level of comfort. I further understand that a massage/bodywork should not be construed as a substitute

for medical examination, diagnosis, or treatment and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental

or physical ailment that I am aware of. I understand the massage therapists/bodyworkers are not qualified to perform skeletal adjustments, diagnose,

prescribe, or treat any physical or mental illness, and that nothing said in the course of the session(s) given should be construed as such. Because

massage/bodywork is contraindicated (should not be done) under certain medical conditions, I affirm that I have stated all my known medical condi-

tions 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 forget to do so. It is also understood that any illicit or suggestive remarks or advances made by

me will result in immediate termination of the session, and will be liable for payment of the scheduled appointment.

Signed: ______________________________________________________ Date: _______________________________________