health history and consent for massage therapy · health history and consent for massage therapy...
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HEALTH HISTORY AND CONSENT FOR MASSAGE THERAPY
Please take a moment to fill out this health history form as completely as possible. The information gathered through your health history provides your massage therapist with necessary information to treat you safely. Please feel free to ask questions about why we are requesting this information. The information you provide us with will be kept confidential unless you submit a written request for us to release your information or if required by law.
GENERAL CONTACT INFORMATION
Name:_______________________________________________________________ Phone:_________________________________
Address:_____________________________________________________________________________________________________
City: ____________________________ Postal Code: ________________________________ Date of Birth: _________________
Occupation: ______________________ Email: _______________________________________*email addresses are not be shared with third parties
Emergency Contact: ______________________________________________________ Phone: ______________________________
How did you hear about us? _____________________________________________________________________________________
Who may we thank for your referral? _____________________________________________________________________________
Have you had a therapeutic massage before? Y / N
Do you have any difficulty lying on your front, back or side? Y / N If yes, please explain ____________________________________
Do you have any allergies/sensitivity to oils, essential oils, lotions or ointments? Y / N If yes, please explain ____________________
What is your primary complaint?_________________________________________________________________________________
Can you describe it? (circle one or more) DULL SHARP SHOOTING ACHY NUMB TINGLING STIFF
Pain scale: (low) 1 2 3 4 5 6 7 8 9 10 (high) Does the pain radiate anywhere? _____________________________________________
Does anything aggravate your symptoms? _________________________________________________________________________
Does anything relieve your symptoms? ____________________________________________________________________________
When did your symptoms begin? _________________________________________________________________________________
Have they changed? & How? ____________________________________________________________________________________
Is this condition interfering with (circle all that apply): WORK SLEEP DAILY ROUTINE EXERCISE HOBBIES
Please explain _________________________________________________________________________________________
Have you seen any other health care practitioner concerning this complaint? Medical Dr ___ Chiropractor ___ Physiotherapist ___
Acupuncturist ___ Massage therapist ___ Have you had results? ____________________________________
Lifestyle:
Energy Levels (circle): Low Average High
Do you feel stressed? Y / N Cause? ___________________________________________________________________
Regular Exercise? Y / N Type _________________________ Frequency _____________________________________
Regular sleep habits? Y / N
Computer use? Y / N How many hours per day (on average)? ______________________
Please indicate on the diagram below the location(s) of your symptoms:
Have you experienced any of the following conditions? If so, please indicate which ones:
Cardiovascular:
High blood pressure
Low blood pressure
Chronic congestive heat failure
Heart attack
Phlebitis/varicose veins
Stroke/CVA
Pacemaker or similar device
Heart disease
Atherosclerosis
Other: _______________
Respiratory:
Chronic cough
Shortness of breath
Bronchitis
Asthma
Emphysema
Smoker?
Head and Neck:
History of headaches
History of migraines
Vision problems
Vision loss
Ear problems
TMJ
Other: _______________
Soft Tissue/Joint pain:
Neck
Upper back/shoulders
Arms/hands
Mid back
Low back
Hips
Legs
Knees
Feet
Strains/sprains
Other: ____________________
Gastrointestinal:
Diarrhea
Indigestion/heartburn
Constipation
Other: ____________________
Infections:
Hepatitis
Skin conditions/rash
TB
HIV
Herpes
Open sores/wounds
Other: _____________________
Women:
Pregnant. Due:______________
PMS/Menopause
Previous c-section. Date ______
Other: _____________________
Other:
Loss of sensation. Where:____________________
Diabetes. Onset:_____________________
Allergies. To what? __________
Epilepsy
Cancer. Where:____________________
Fibromyalgia
Swelling in the ankles
Bruise easily
Arthritis
Hemophilia
Osteoporosis
Mental illness
Dizziness/fainting
Scoliosis
Autoimmune Disorder (Lupus, MS, RA etc)
Current fever
Swollen glands Other: _____________________
Are you currently taking any medication or pain killers: (please list them and the condition they treat) _________________________
____________________________________________________________________________________________________________
Surgery/injuries/hospitalization: (date, past & current symptoms) ______________________________________________________
____________________________________________________________________________________________________________
Do you have any internal pins/wires/artificial joints? _________________________________________________________________
How would you rate your overall health? (circle) Fair Good Excellent
What are your goals for your massage therapy treatment?____________________________________________________________
____________________________________________________________________________________________________________
Is there anything else that you feel would be useful for your massage therapist to know in order to plan a safe and effective massage treatment for you?___________________________________________________________________________________________
Informed Consent to Massage Therapy Treatment
I understand that the Massage Therapist is providing massage therapy services within their scope of practice.
I hereby consent for my therapist to treat me with massage therapy for the previously noted purposes including such assessments,
examinations and techniques, which may be recommended, by my therapist.
I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder.
I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I visit my personal
physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to
the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me
and I assume those risks.
I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my
medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my
responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete
to the best of my knowledge.
I understand that all information/conversation exchanged during a treatment session or about a treatment session remains
confidential for the safety and well-being of the myself and the therapist.
I understand that if I am late to an appointment, the treatment session will be shortened and I will be charged for the full session. I
understand the cancellation policy and that I must provide 24 hours notice of cancellation of an appointment. I understand that I
may be charged the full fee for a missed appointment if proper cancellation notification is not provided to the clinic.
I understand that intoxication (any alcohol consumption) during a massage treatment is not permitted. If I attend a treatment
session intoxicated, I will be asked to leave and charged the full price for the treatment session. I acknowledge that sexual
innuendos, language and/or behavior will not be tolerated. Should this occur, I understand that the therapist will end the treatment
session immediately and I will be charged the full amount for the session.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I
confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment
as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I
understand that at any time I may withdraw my consent and treatment will be stopped.
Client Name: ___________________________________ Signature of Client/Guardian:_____________________________________
Date Signed: ___________________________________ Therapist Name:_____________________________________________
Notes:
Date of Initial history: _________________________
Update 1: ___________________________
Update 2: ___________________________
Update 3: ___________________________
Prenatal Massage Release Form
Massage therapy during pregnancy has been shown to be beneficial for a number of common complaints such as fatigue,
musculoskeletal pain, sciatica, edema, and many others. However, there are risks associated with specific conditions that may occur
during pregnancy.
It is important to inform your massage therapist of any current or previous conditions so that a safe and effective treatment can be
planned for you. Some of these conditions may make massage therapy during pregnancy contraindicated. Please check any of the
conditions and symptoms below that you have currently or have had in the past:
History of miscarriage
Gestational diabetes
Cardiac, pulmonary, liver or renal disorders
Mother’s age under 20 or over 35
Pitting edema
Epilepsy or other convulsive disorders
Placental or cervical dysfunction
Abdominal pain
Leaking of amniotic fluid
Fever
Sudden edema/swelling
Severe headaches
Preeclampsia
History of any high-risk pregnancy
Drug exposure
Multiples
Hypertension
Genetic abnormalities
Fetal growth retardation
Bloody discharge
Sudden weight gain
Diarrhea
Decrease in fetal movement over 24-hour
period
Severe nausea or vomiting
Previous c-section(s)
I, ____________________________________________, have read the aforementioned conditions and symptoms and have
informed my therapist of any conditions that I am currently experiencing or have experienced in the past. The massage therapist
has discussed this information with me and provided opportunity for any questions. I have disclosed all high-risk factors of my
pregnancy.
I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I
agree that my healthcare provider/physician has given me clearance to receive massage therapy.
I understand the information contained on this form and confirm that (1) I am receiving medical care including regular check-ups
with a licensed healthcare provider. (2) I have disclosed any conditions or symptoms that may make massage therapy
contraindicated and (3) I am experiencing a low-risk pregnancy.
I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to
replace appropriate medical care. I release the massage therapist of all liability for any harm that may unintentionally occur during
my treatment(s).
I am currently _______ weeks/months pregnant. I am due __________________________
Client Name: _______________________________ Client Signature: _____________________________________________
Date Signed: _______________________________ Therapist Name: _____________________________________________
DIRECT BILLING AND CANCELLATION POLICY
If I am unable to make a scheduled appointment I must provide 24 hours advance notice to avoid being charged a missed appointment fee of 100% of my scheduled visit. I agree to pay my full account at the time of each visit or treatment, including fees for services, cost of supplements, cost of laboratory tests, administrative fees as well as any other applicable fees. Anyone who either forgets or consciously choses to forgo their appointment for whatever reason will be considered a “no-show”. They will be charged for their “missed” appointment and all future services will be denied until the account is settled. In the event that an appointment is cancelled or rescheduled with less than 24 hours’ notice you are subject to a late cancellation fee of $50. Credit card information provided below will only be used in the event that less than 24 hours’ notice was provided for cancellations or changes, no show appointments or if insurance direct billing does not pay Harmony Health Integrative Centre the amount authorized. In the event the credit card does not work, the balance owing must be paid within 5 business days of being advised. Harmony Health Integrative Centre reserves the right to cancel any future appointments until this is done. Signature of Patient or Guardian: ________________________________ Date: ___________ Credit Card information: Visa MasterCard Patient(s) Name: _____________________________________________________________ Name on Card (please print): ___________________________________________________ Credit Card Number: __________________________________________________________ Expiration Date (Month/ Year): _______________________ CVV:_____________________
Cardholder’s Full signature: ____________________________ Today’s Date: ____________