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Have you had a Professional Massage Before this Visit?
Reason for today's massage(major complaint)?
What, if any, Treatment have you had for this Condition?
Is there anything that makes the condition worse?
If Yes, Please Explain:
Desired Massage Pressure?

Health Conditions (check box if conditions apply to you)

Name Yes No
Headaches:
Cancer:
Heart or Circulation Problems:
Major Accident:
Neck or Back Injuries:
Numbness:
TMJ:
Joint Surgery:
Vericose Veins:
Diabetes:
Sprains or Strains:
Arthritis or Tendonitis:
Abnormal Skin Condition:
High or Low Blood Pressure:
Blood Clots:
Fibromyalgia:
Asthma:
COPD:
Edema:
Bursitis:
Emphysema:
Allergies:
Sciatica:
Pregnancy:
HIV/AIDS:
Sinusitis:
Stents:
Pacemaker:
Recent Injuries:
Other:
Describe above checked health conditions:
Other Significant Health Conditions:
What you can Expect in a Professional Massage:
  1. A Safe & Professional Environment & Approach; To be Treated with Respect
  2. To Have Privacy While Undressing & Dressing; To Be Draped Except for the Area Receiving Work
  3. To be Accepted Without Judgment; To be Able to Stop the Therapy At Any Time
  4. To be Listened to Carefully; To Talk, or not to Talk
  5. To Have Control Over How Much Pressure is Used
Policies:
I have Read & Agree To our Policies
Client Informed Consent:
Please Type in Your Name and Today's Date Agreeing to the Above Statements
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