Heart’s Content Healing

Client Health History and Massage Therapy Consent Form

NAME______________________DATE_______________DATE OF BIRTH_______________

PHONE NUMBER(___)-____________________ E-MAIL_______________________________

EMERGENCY CONTACT________________________________________________________

DOCTOR’S NAME/LOCATION____________________________________________________

CHIROPRACTOR’S NAME/LOCATION_____________________________________________

YOUR OCCUPATION/HOBBIES__________________________________________________

HAVE YOU EVER RECEIVED A THERAPEUTIC MASSAGE?  ____YES    ____NO

IF YES, HOW OFTEN?______________________________

RATE LEVEL OF DAILY STRESS:    ____LOW                ____MED                ____HIGH

DATES AND NATURE OF PAST OR RECENT SURGERIES/INJURIES/ACCIDENTS:

______________________________________________________________________________

ANY “RANGE OF MOTION”

ISSUES IN ANY OF YOUR JOINTS?________________________________________________

ANY SKIN CONDITIONS, CIRCULATORY ISSUES, ALLERGIES OR ANY OTHER HEALTH CONCERNS?___________________________________________________________________

______________________________________________________________________________

PLEASE, LIST YOUR MEDICATIONS AND INCLUDE THEIR PURPOSE(S):

____________________________________________________________________________________________________________________________________________________________

MASSAGE PRESSURE PREFERENCE:                         INDICATE AREAS OF TENSION:

___LIGHT        ____MED        ____FIRM

-Please note that the pressure will vary throughout your massage session and therapist will “check in” with you, though, you are invited to request changes in pressure at any point, so that the massage meets your needs.

-Also, please, don’t hesitate to let therapist know if any other changes can be made to increase your comfort & relaxation.

READ AND SIGN: I have notified my therapist of all known medical conditions and injuries and agree to inform therapist of changes in my health conditions. I understand that a massage therapist cannot diagnose illness, disease or any other medical, physical or emotional condition.

I understand that the services offered today are for therapeutic and relaxation purposes, are not a substitute for medical care and are non-sexual. I hereby offer my consent to receive these services and hereby waive and release my therapist from any and all liability, past, present, and future.

Signed_______________________________________________Date_____________________