CLIENT HEALTH HISTORY & INFORMED CONSENT

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number*

Please enter a valid phone number.

Can you receive texts at this number?

YesNo

If the therapist needs to reach me quickly (scheduling question, illness, etc.), it is acceptable to call me between the hours of Time and Time .

Date of Birth*

Date

Emergency Contact

Emergency Contact's Phone Number

Please enter a valid phone number.

How did you hear about the therapist?*

FriendOnline searchOther

Name of referrer

Can the therapist let the referrer know you came in today so they can get the referral discount?

YesNo

Please sign to authorize therapist to let the referrer know you came in today. No other information about you or your appointment will be given to the referrer.

Do you have any current known

Please elaborate on your injuries.

Please tell me more about your bruises or rashes.

Please elaborate on your infections or contagious disease.

Please elaborate on your allergies or sensitivities.

Please tell me more about your blood clots.

Which joints are affected by your arthritis or bursitis?

Please elaborate on your heart problems.

Please elaborate on your kidney problems.

Please elaborate on your emotional sensitivities.

Which discs?

When is your due date?

Date

Do you have a health care provider you would want me to contact regarding your bodywork?

YesNo

Health care provider's name

Health care provider's phone number

Please enter a valid phone number.

Any previous injuries or surgeries that might be affecting current pain patterns?

YesNo

Please list injuries or surgeries along with dates, as best as you can remember.

Please make sure to add "left" or "right" when appropriate.

Are you currently taking any medication?*

YesNo

Please list medications, dosages, and what they are treating.

Are you...

Right handedLeft handedAmbidextrous

Do you feel you "hold" stress or tension in any part of your body?

YesNo

Where do you commonly hold tension?

Do you experience any of the following?

Chronic headachesChronic backachesBruxism (clenching, grinding of teeth)Tightness in jaw (especially upon waking)

What types of activities do you do? (include hobbies, exercise, and any work-related physical activities)

Please list how often you do these activities

Have you ever had bodywork/massage done before?

YesNo

What was the reason for the bodywork (e.g. relaxation, pain relief, physical therapy, etc.)?

When was your last massage?

Are there areas you prefer NOT to have worked or pet peeves about previous massages?

What type of pressure do you prefer?

LightMediumStrong

Is there any other information you feel would be helpful to share with the therapist at this time?

What are your goals for today's massage? (E.g. relaxation, recovery from injury, pain management, etc.)*

By signing here, I verify that I have filled out my health history completely and honestly.*

I understand that the massage I receive is for the purpose of stress reduction and relief from muscular tension, spasm, or pain, and to increase circulation. If I experience any pain or discomfort (pressure, temperature, etc.), I will immediately inform the therapist so that the pressure or methods can be adjusted to my comfort level. I do not hold her responsible if I fail to do so.

I realize that this massage is therapeutic and non-sexual in nature and any inappropriate behavior on my part will result in immediate termination of the session and I will be responsible for paying the full session cost.

I understand that massage professionals do not diagnose illness or disease or perform any high-velocity adjustments, nor do they prescribe any medical treatments, and nothing said or done during the session should be construed as such. I acknowledge that massage is not a substitute for medical examination or diagnosis and that I should see an appropriate health care provider for those services.

Because massage should not be performed under certain circumstances, I agree to fill out my health history honestly and completely, and keep the therapist updated as to any changes in my health profile, and I release her of liability if I fail to do so.

If I am feeling ill, I will postpone my appointment until I'm feeling better. For the comfort of the therapist and the clients seen after me, I will refrain from wearing perfume or cologne to my session.

I also understand that the therapist's time is important and missed appointments mean missed income for her. Therefore, if I need to cancel or postpone an appointment, I will give her at least 24 hours' notice or pay a $25 cancellation fee if the appointment is not filled, to be paid before my next appointment. If I forget or forgo my appointment with NO previous notice (before the session start time), I am responsible for the full cost of my session.

I realize that if I want my full hands-on time, I should arrive five minutes before my appointment time in order to go over my current bodywork goals, disrobe, and be on the table by my appointment time. Regardless of my arrival time, my appointment will end on time to make sure those following my appointment aren't delayed.

I will fill out a health screening form before each appointment to verify that I am feeling well enough for bodywork and am not likely to spread any contagions to the therapist or the clients seen after me.

By signing my name below, I acknowledge that I have read and agree to all of the above statements.*

Is the client a minor (under the age of 18)?

YesNo

Name of parent or guardian

First NameLast Name

By my signature I agree to the above statements and I authorize Mischa Bradford to provide therapeutic massage to my child or dependent and I will be present in the room for the entirety of the massage.