A Keys Massage
Keys to Relaxation & Inner Balance

Client Health History Form

   
   

A Keys Massage                                         Intake Form                       

Alicia N Keys LMT #15489

Client Information

Client Name ____________________________Date___________DOB___________

Address_________________________City___________State____Zip____________

Occupation___________________ Cell____________ Other Phone______________

 E-mail_________________Emergency Contact_____________   Phone___________

General Heath Information

 

What are typical activities (things that cause stiffness or pain)? ____________________________________________________________________

____________________________________________________________________

What substances are you taken (medications, supplements, herbs, alcohol, ect.)? ___

_____________________________________________________________________

What are you current massage goals? _______________________________________

 Are there any areas you wish you avoid (abdomen, buttocks, etc.)? ____________________________________________________

 

Current Area(s) of Pain or Stiffness/Area(s) of Focus

 

Area #1 _________________Severity of pain/stiffness (1-10)____ Frequency_________

Duration of pain/stiffness?__________What makes pain/stiffness worse?_____________

 

Area #2 _________________Severity of pain/stiffness (1-10)____ Frequency_________

Duration of pain/stiffness__________What makes pain/stiffness worse?_____________

 

Medical History Please include types, approximate date and treatment received

Surgeries________________________________________________________________

Injuries_________________________________________________________________ 

Major Illness(s)___________________________________________________________

 

Health Concerns                             Comments

                                                                

Pain   Numbness   Altered Sensations    Fatigue    Headaches   __________________

 

Sleep Disturbances    Infections     Swelling      Allergies           ___________________

 

Skin Conditions     Head Injury    Depression     Thyroid            ___________________

 

Stroke    Anxiety    Diabetes    Gastric Reflex     Ulcers            ____________________

 

Kidney Stones    Gas   Bowel Problems   Bladder Problems       ___________________

 

Urinary Tract Problems       Cancer          Other                          __________________

 

Cardio. & Repertory

 

Anemia     Arteriosclerosis     Blood Cots   Varicose Veins               __________________

 

Phlebitis    Hypertension      Asthma     Hart Attack                   ___________________

 

Heart Disease Angina   Congestive Hart Failure   Other            ___________________

 

Muscle & Joint Specific

 

Arthritis   Osteoporosis    Scoliosis    Strains    Sprains              __________________

 

Fractures   Bursitis   Tendonitis    Disk Problems   Other           ___________________

 

Policies/ Consent for Treatment

 

Late/cancellation fees:  Late fees of $15 will be imposed if client is 15+ minutes late and will have the possibility of being rescheduled. If the practitioner is 15+ minutes late the client will receive a $15 discount w/the option to reschedule. If the client fails to give a least 12 Hrs notice to cancel an appointment client will be billed 50% of the cost of the treatment. If the practitioner late cancels client will receive 50% off their next treatment.

 

Sexual Harassment: Is grounds for immediate termination of treatment w/ full payment for treatment(s) scheduled required. Some example are:  improperly touching self or practitioner, client undraping self, sexual comments/questions, improper use of table, etc.

 

Consent for Treatment: I verify that all the information provided is correct and current to the best of my knowledge I have been informed of possible after affects of treatment(s) being given and fully consent to receive treatment at this time.

Signature__________________________________________________Date_______

 

 

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