Message Therapy Patient Form Massage Order Number Confidential Patient Information Name: * Today's Date: * Address: * Postal Code: * Home Phone #: Cell Phone #: Occupation: Employer: Birthdate: Email: * Who may we thank for referring you to our clinic? Have you had message therapy before? * Yes No Medical Doctor: Date of last exam: Chiropractor: Are you presently being treated? Yes No Physiotherapist: Are you presently being treated? Yes No Female: Are you pregnant? Yes No Are you on medications now? Yes No If Yes, please list: Have you ever been involved in any motor vehicle accidents? Yes No Date: Have you been involved in any other accidents? Yes No Date: Have you ever been knocked unconscious? Yes No Date: Do you have any internal wires, artificial joints, pacemakers or special equipment that we should be aware of? Yes No If Yes, what: Do you have difficulty with any of the following? GENERAL Allergy Cancer Chills Convulsions Depression Diabetes Dizziness Epilepsy Fainting Fatigue Fever Fibromyalgia Goiter Headache Hypoglycemia Immune Disorder Loss of Sleep Nervousness Numbness / Tingling Stress Sweat / Tremors Other GASTRO-INTESTINAL Acid Reflux Belching or gas Colitis / IBS Constipation / Diarrhea Difficult Digestion Gall Bladder trouble Hemorrhoids Kidney problems Stomach / Ulcer Other MUSCLE AND JOINT Arthritis / Bursitis Carpal Tunnel Syndrome Foot / Ankle trouble Fractures Gout Low Back / Hip Pain Sciatica Strains or Sprains Swollen joints Other EYES, EARS, NOSE AND THROAT Asthma Ear Noises Frequent Colds Frequent Earaches Frequent Sore Throat Hay Fever / Allergies Chronic Hoarseness Sinus Infection Other RESPIRATORY Asthma Chest Pain Chronic Cough Difficulty breathing Emphysema Liver problems Other CARDIO-VASCULAR Hardening of Arteries High blood Pressure Low Blood Pressure Heart trouble Poor Circulation Stroke Varicose Veins Other SKIN Bruise easily Dryness Eczema Itching Psoriasis Other GENITO-URINARY Bladder Infections Blood in Urine Frequent Urination Painful Urination Prostate trouble Other WOMEN ONLY Excess Menstrual Flow Hot Flashes Irregular Cycle Lumps in Breasts Painful Menstruation Other List surgeries, broken bones and Infectious Diseases: I have disclosed all the medical conditions that I am aware of. I release the therapist from all liability concerning any problems that may arise from the massage from any information knowingly omitted. I understand that massage therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe and that nothing said in the course of the session should be construed as such. It is also understood 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 for the full scheduled appointment. Kindly allow 24 hours cancellation notice for all appointments. A cancelled appointment that does not provide the required 24 hrs notice will result in a charge for the full fee of the massage booked. Our cancellation policy was created to best serve our patients and to create opportunities for new appointments. To maintain a calming atmosphere, children are not permitted. For the safety of your children, we ask that they not accompany you to the appointment as they cannot be left unattended. Date: * Do you agree with these conditions? * YesNo
