Client Name *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you ever experienced professional therapeutic massage before? *

Yes

No

Which of the following have you experienced?

Motor Vehicle Accident

Sports Injury

Bad fall or other physical trauma

Have you experienced other therapies?

Chiropractic

Physical Therapy

Acupuncture

Other

Do you suffer from stress? *

Yes

No

Do you have diabetes? *

Yes

No

Are you pregnant? *

Yes

No

Do you suffer from arthritis? *

Yes

No

Do you have high blood pressure? *

Yes

No

Do you suffer from epilepsy or seizures? *

Yes

No

Do you suffer from joint swelling? *

Yes

No

Do you have varicose veins? *

Yes

No

Do you have any contagious diseases? *

Yes

No

Do you have any cardiac, circulatory or blood clotting problems? *

Yes

No

Do you have osteoporosis? *

Yes

No

Do you have any allergies? *

Yes

No

Do you bruise easily? *

Yes

No

Do you have tension or soreness in any specific areas? *

Yes

No

Have you broken any bones or other injuries in the last 2 years? *

Yes

No

Have you had any surgeries? *

Yes

No

Do you experience any numbness, tingling or stabbing pains? *

Yes

No

I understand that the massage work I receive is provided for the purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and or strokes may be adjusted to my level of comfort. I further understand that massage should not be considered a substitute for medical examination, diagnosis, or treatment that I should see a physician, chiropractor, or other qualified medical specialists for any mental or physical ailment of which I am aware. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, or treat any physical or mental illness, and that nothing said during this session given should be construed as such. Because massage therapy should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile an understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of this session, and I will be liable for payment of the scheduled appointment. *

Yes, I agree

I acknowledge and accept that this practice and therapist does not participate in any no-fault, workmen’s compensation or cases of other legal actions for payment from injury. I understand full payment is due at time of service. Documentation of this form and proof of payment are available upon request. *

Yes, I agree

Consent to treat a minor: I hereby authorized Body Be Well Solutions to administer massage therapy to my child or dependent as they deem necessary.

Yes, I agree