Stress Waived-862 Minot Ave,  Auburn, ME 04210     207-784-8002

Confidential Personal Information

 

Last Name: ___________________________  First: _____________________  Middle: ___________

 

Nick Name: _____________________ Date Of Birth: _____________Age____   Gender: {    }M   {     }F

 

MAILING Address: ________________________________________  City:_________________________

 

State:________   Zip: ______________           Email Address: ______________________________________(for appt reminders)

 

Home Phone: ________________  Cell #: ____________________         Work #: _________________

 

I prefer to be contacted and get appointment reminders through (please circle all that apply):  email         text         phone        

 

Whom may we thank for referring you to our office/How did you find us? __________________________________________

 

Has any other member of your family been treated at Stress Waived?  {         }Yes  {         }No    Who? _______________________

 

Employer: _______________________________________Occupation: ________________________________

 

Are you primarily Sitting or Standing? (circle one).                          Do you stretch daily?  Yes{         }  No {         }            

 

Past treatments with other Practitioners you see (P/T, Chiro, LMT, etc):_________________________________

 

Current Physician: ____________________________                Ph #: ___________________________

Emergency Contact:    (Adult person please-other than yourself)

 

Name: _______________________________ Relationship: _____________________ Phone #: ___________________

 

We here at Stress Waived encourage you to be open to new information on the effectiveness and fundamental role of health including exercise, stretching, hydrotherapy, stress management, energetic/mental work, essential oils (aromatherapy) and more.  We encourage you to make your own health decisions based upon your own research and in partnership with your primary health care providers (ND, MD, etc.)

 

Please know that the information you receive in your session(s) is not medical advice; it is sharing of knowledge and information from the therapists’ education, research, training, and 20+ years of hands on bodywork experience. This is not intended to replace the relationship you have with your primary health care providers but to enhance it and your wellness plan.

 

By signing below, you acknowledge and understand the following information:

 

-- The information and services provided at Stress Waived are not used to prescribe, recommend, diagnose or treat a health or mental problem or disease.  Massage therapists do not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulation.  It has been made clear to me that massage is not a substitute for medical examination or diagnoses and that Stress Waived recommends that I see a physician for any physical ailment that I might have.

 

-- You reserve the right to seek or ask wellness care advice, counsel, recommendations, suggestions, assessments, test and/or treatments, regimens or modalities from any doctor, health care provider or specialist of my choice for any health reason or purpose.

 

--You have stated ALL your known medical conditions, both past and present.  You will take it upon yourself to keep the massage therapist updated on your physical and mental health, now and in the future as changes occur.  You acknowledge that failure to do may put yourself in harms way at your own volition.

 

-- You clearly understand that massage therapy treatments are your personal financial responsibility, and agree to pay for these services at the time of the treatment.  I also understand that Stress Waived may bill me in full for appointments broken without 24 hours prior notice and agree to pay any balance on my account if for some reason one occurs.

 

-- You also agree to hold harmless any and all personnel of Stress Waived from any present of future liability.                                                                                                                                

The information on this page and the medical history pages are correct to the best of my knowledge.  Signature of responsible Party.

 

X ______________________________________________________       Date: ______________________

        {     }Adult Patient               {         } Father   {     } Mother {         } Guardian


Stress Waived  - 862 Minot Ave,  Auburn, ME 04210

 

Date: ____________________

Health History Form

 

Last Name: __________________________ First Name __________________________

 

Reason for Your visit today / Present Condition----------------------------------------------------------

Are you here for: Treatment /specific issue/Area?  or   Relaxation/De-Stress? {circle one}

Current problem / compliant: ______________________________________________

How long has this issue been bothering you? ____________Date if poss.___________

Have you had massage therapy before? {        } Yes  {        } No

If yes for what reason/condition? _______________________________________

 

Do you have a long-term wellness goal? If so what is it: ______________________________

 

Do you know how massage can transform your life? __________________________________

 

Do you drink coffee? {   } Yes  {   } No.  How many cups per day? _________

 

Do you drink alcohol?  How often? _______________________

 

Thank you for sharing this information.

 

Please continue to the NEXT page


Conditions/Medical background for Name: ___________________________________________

 

PAIN Information regarding your complaint----------------------------------------------

 

How many hours a day does this pain/Problem affect you? _______

 

On a scale of   0 (no pain)-10 (worst ever) where is your pain TODAY? #________

Typically/On aver? #_______

 

Is the pain worse in the: _____AM   _____Mid-day  ___Evening  ___Night  ___wakes you up

Does the pain get worse/increase after it started? ______________________________________

Does this pain last?   _____Minutes         _____Hours    _____Days   _____Weeks

What do you do that helps reduce/relieve/control the Pain? ____________________________________

 

Are you ever pain free?  {     }Yes   {         }No

 

How many hours a day are you pain FREE? _________

 

When in Pain, please describe all methods or relief that work ! ___________________________

 

MEDICAL History---------------------------------------------------------------------------------

Since massage therapy affects the entire body even when working one area the following medical info. is important and needed.  Please take the time to be specific and accurate while filling this out. Feel free to write-in more details if needed.

 

Family History: Does anyone in your family have…___ Arthritis          ___ Cardiovascular        ___ Respiratory

 

Area(s) of Complaint: Using the number scale 0-10 (0=pain free, 10=extreme pain)

Put a # on ALL areas you have an issue with.

 

___Head              ___Neck (left)                  ___Neck (right)                ___Shoulders (left)        ___Shoulders (right)

___Upper Back (left)   ___Upper Back (right)  ___Mid Back (left)  ___Mid Back (right)

___Low Back (left)          ___Low Back (right)           ___Hips (left)                ___Hips (right)

___Legs (left)                   ___Legs (right) ___Knees (left)                            ___Knees (right)

___Feet (left)                   ___Feet (right) ___Ankle (left) ___Ankles (right)

___Arms (left)                  ___Arms (right)                   ___Elbow (left)             ___Elbow (right)        

___Wrist (left)                  ___Wrist (right)                    ___Hands (left)            ___Hands (right)

 

Please Check all that apply: Put a P=past, C=current

 

HEADACHEs and type:

___Chronic Daily Headache        ____Cluster          ____Migraines           ___Sinus        ___Tension

 

BLOOD

___Anemia           ___Bleeding disorder        ___Hemophilia ___Hepatitis            ___HIV

 

CARDIOVASCULAR

___Angina   ___Blood clots  ___Congestive Heart Failure  ___Heart Attack  ___Heart Disease ___High Blood Pressure ___Low Blood Pressure               ___Pacemaker           ___Lymphedma  ___Varicose Veins

___Myocardial Infarction           ___Raynauds Disease          ___Rheumatic Heart Dz       ___Valve Disorder

 

GASTROINTESTINAL

___Celiac disease          ___Constipation  ___Crohns Dz  ___Diarrhea___Diverticulitis               ___Digestive Condition        ___Eating Disorder        ___Irritable Bowel               ___Poor appetite           ___Stomach Disorder

 

ENDORINE

___Acute Pancreatitis                   ___Diabetes         ___Hyperthyroidism  ___Hypothyroidism

HEARING

___Conductive Hearing loss         ___Ear Problems              ___Meniere Dz          ___Motion Sickness

___Tinnitus                                   ___Vertigo                       ___Ear Problems

 

IMMUNE

___Allergies(note below)              ___Cancer           ___Hodgkin Lymphomia        ___Leukemia

___Lupus                         ___Rheumatoid Arthritis               ___Non-Hodgkin’s lymphoma

 

KIDNEY

___Bladder Disorder        ___Chronic Kidney Dz ___Kidney Stones               ___Renal Cysts

___Urinary Incontinence               ___Urinary Tract Infection

 

EMOTIONS/ MEMORY

___Anxiety Disorder                    ___Mod disorder             ___Stress          ___Substance abuse disorder

 

MUSCULOSKELETAL

___Bone Dz                     ___Fibromyalgia                           ___Fracture                     ___Gout               

___Joint injury               ___Muscular Dystrophy               ___Osteoarthritis                 ___Osteoporosis

___Strain/Sprain               ___Scoliosis                                 ___Jaw Pain                     ___Broken Bones

 

NEUROLOGICAL

___Brain Disorder         ___Brain Injury   ___Burning           ___Stroke            ___Epilepsy  ___Chronic Pain Disorder

 ___Dizziness   ___Herniated Disc(s)        ___Seizure Disorder            ___Shingles          ___Tingling              ___TIA

 

RESPIRATORY

___Asthma                       ___Bronchitis                   ___Chronic Cough              ___COPD              ___Respiratory conditions

 

SKIN

___Acne              ___Athletes Foot              ___Bruise Easily                        ___Herpes                    ___Rash

___Melanoma               ___Psoriasis               ___Rosacea  ___Skin Condition  ___UV burn

REPRODUCTIVE         

___Breast disorder           ___Menopause                ___Ovarian cysts/tumors        ___Uterine Disorder

___Pregnant

 

MISCELLANEOUS

___Insomnia                     ___Mental Illness             ___Surgical pins/wires         ___Vision loss/problems

____Other issues NOT listed above: ____________________________________________________

 

 

Have you been hospitalized during the past two years ?   {         } Yes    {         } No    

                Why ? ______________________________________________________________________

 

Please note ALL / ANY medication, pills. Prescribed or Over The Counter (including aspirin, Tums, etc..)?  Every thing we put in our bodies affects us-especially our muscles and/or circulation

 

                Medication Name                                  For What Condition ?

________________________ for           ___________________________________

________________________ for           ____________________________________

________________________ for           ____________________________________

________________________ for           ____________________________________

 

Are you ALLERGIC to anything ?              {         } Yes          {     } No

                What ? _______________________________ (IE: Nuts, Oils, Foods, Lotions, Etc...)

 

 

Bodywork History--------------------------------------------------------------------------------------

 

Have you ever received a professional massage? {         } Yes          {         } No   Where? _________________

                For what reason/condition: _____________________________________________________

                What did you like and/or dislike about our experience? _______________________________

                ____________________________________________________________________________

 

Are you aware of any SWELLING, Lumps, Breakouts, Rash, Etc. ? {         } Yes               {         } No

 

I have stated all medical conditions that I am aware of and will update the practitioner of any changes in my health status.

 

 

By signing below, you acknowledge and understand the following information:

 

-- The information and services provided at Stress Waived are not used to prescribe, recommend, diagnose or treat a health or mental problem or disease.  Massage therapists do not prescribe medical treatment or pharmaceuticals, nor do they perform spinal manipulation.  It has been made clear to me that massage is not a substitute for medical examination or diagnoses and that Stress Waived recommends that I see a physician for any physical ailment that I might have.

 

-- You reserve the right to seek or ask wellness care advice, counsel, recommendations, suggestions, assessments, test and/or treatments, regimens or modalities from any doctor, health care provider or specialist of my choice for any health reason or purpose.

 

--You have stated ALL your known medical conditions, both past and present.

 

--You will take it upon yourself to keep the massage therapist updated on your physical and mental health, now and in the future as changes occur including but not limited to medications, surgeries, hospitalizations.  You acknowledge that failure to do so may put yourself in harms way at my own volition.

 

-- You clearly understand that massage therapy treatments are your personal financial responsibility, and agree to pay for these services at the time of the treatment and you are aware that if not paid you will be billed for any/all amounts due and unpaid. You also understand that Stress Waived may bill you in full for appointments broken without 24 hours prior notice and agree to pay any balance on your account if for some reason one occurs.

 

-- You also agree to hold harmless any and all personnel of Stress Waived from any present and/or future liability.

                                 

-- I want you to feel that you've received incredible value for your money and were not only satisfied but also absolutely delighted with your session. If not, then let me know in person, by phone, mail, fax, or email and I will refund ANY amount up to the amount you paid for the service (every cent you've paid), no questions asked!                                                  

 

Signature of responsible Party 

X _________________________________________  Date: ____________________

  {     }Adult Patient   {         } Father         {         } Mother            {         } Guardian

 

The information you have provided is confidential. It allows us to tailor the session towards your needs.  We will briefly go over some questions and inform you of our policies and answer any questions you have about us the treatment, or bodywork in general.