Client Information, Health Intake
Dig'n Deep Back and Body Works
Therpeutic Massage
Rhonda Cavers, LMT 2988M
Name:______________________________________________________Home Phone: ( )_________-_____________
Address:_____________________________________________________Cell Phone: ( )_________-_____________
City:______________________________State:_______Zip:___________Work Phone: ( )_________-_____________
E-Mail:_______________________________________________________ Date of Birth:__________________________
Occupation:__________________________________Referred by:______________________________________________
In case of emergency:_____________________________________________Phone: ( )__________-_____________
General & Medical Information:
Please list all medications________________________________________________________________________________
qYes qNo Have you ever had professional massage? qYes qNo Do you have high blood pressure? qYes qNo Are you diabetic? qYes qNo Are you wearing contact lenses? qYes qNo Are you pregnant? | qYes qNo Have you had any broken bones in the past two years? qYes qNo Are you very sensitive to touch / pressure in any area? qYes qNo Have you ever had surgery? If yes, please explain in the comments area of this form. |
How many weeks/months? qYes qNo Do you suffer from seizure disorders qYes qNo Do you experience frequent headaches? explain qYes qNo Do you suffer frequently from stress? explain qYes qNo Do you suffer from back pain? explain | qYes qNo Do you have tension or soreness in a specific area? qYes qNo Do you have numbness or stabbing pains anywhere? qYes qNo Do you have any other medical condition that I should be aware of?
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Comments:________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING INFORMATION AND SIGN WHERE INDICATED.
If you have a specific medical condition or specific symptoms, a referral from your primary care provider may be required prior to service. I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I neglect to do so.
It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Client Signature:__________________________________________________________________ Date:___________________________________
Information and Suggestions for the Client
u Prior to your massage, remove all jewelry. Pull long hair back with a clip.
u As a rule, massage is given while you are unclothed. We provide a top sheet and / or towel. Modesty and comfort levels vary from person to person. You may choose to wear undergarments or a swim suit or nothing at all. This is YOUR massage and you should feel as comfortable as possible.
u During your massage, you may want to give your therapist feedback as to pressure (deeper or lighter) or point out painful or ticklish areas of your body.
u Feel free to ask your therapist any questions about their procedure.