Wyndwalkr

Healing for Body and Spirit

Personal Information:

Name_________________________________________________________Date________________

Address______________________________________________________________________________

Birthdate____________________________Phone number/s______________________________

Occupation________________________________________email_______________________________

Emergency contact____________________________________________Phone number_________

Relationship to you______________________________________________________________________

Health History:

Recent illnesses, injuries, or accidents within last 12 months? ____________________________________

Previous surgeries or health issues that still affect your well being?________________________________

Please list any medications that you currently take (both prescribed and over-the-counter)_________

_____________________________________________________________________________________

Have you had massage before?______ What type/s?_________________________________

Please circle any of the following conditions that may apply to you at this time:

Allergies                                         Insomnia

Anxiety                                             Leg/foot problems

Arms/hand problems                   Muscular problems

Asthma                                            Neck problems

Back problems                               Numbness/ tingling

Bruises                                             Paralysis

Cancer                                              Pregnancy

Contact lenses                                Respiratory problems

Depression                                      Seizures

Diabetes                                           Skin conditions

Fatigue                                             Smoker

Gastrointestinal discomfort         Spinal problems

Headaches                                     Stress

Heart problems                             Urinary problems

High blood pressure                    Varicose veins

Contraindications for massage

You should not receive massage therapy if you have any of the following conditions:

• Fever

• Infectious skin conditions

• Inflammatory conditions in the acute stage

• Blood clots

• Inflamed lymph nodes

• Contagious diseases

• Edema due to heart or kidney failure

• Acute trauma or recent surgery ( must be at least 6 wks. post-op and have a doctor's written permission)

• Under the influence of alcohol or drugs

Please consult your doctor if you are unsure if massage therapy is appropriate for your particular health condition.

Scope of Practice

Massage therapy is not intended to replace the services or your physician, physical therapist, chiropractor or other licensed medical provider. You should consult your doctor in all matters that relate to your health, especially in regards to conditions and symptoms that require a medical diagnosis. Massage therapy or therapeutic massage does not include diagnosis, treatment of diseases or any procedures that requires, by law, licensing to practice medicine, physical therapy or chiropractic care.

Consent for Massage Therapy

I am choosing to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for therapy. I understand that there is no guarantee of success or effectiveness of these techniques as used in any number of appointments. I have listed all medical conditions that I am presently aware of and will inform my massage therapist of any changes in condition and/or medication. I understand that I may withdraw my consent for massage at any time.

Signature__________________________________________________Date_______________________

Parent's Signature (if under 18)_____________________________________Date___________________