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CLIENT INTAKE - HEALTH HISTORY - INFORMED CONSENT
DATE *
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PHONE NUMBER *
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E-MAIL ADDRESS *
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PREFERRED METHOD OF COMMUNICATION *
FIRST and LAST NAME *
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DATE OF BIRTH *
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ADDRESS, CITY, STATE, ZIP CODE *
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EMERGENCY CONTACT NAME and PHONE NUMBER *
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WHAT ARE YOUR TREATMENT GOALS? *
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DO YOU HAVE ANY ALLERGIES TO OILS, LOTIONS OR OINTMENTS? *
IF YES, LIST YOUR ALLERGIES TO OILS, LOTIONS OR OINTMENTS. IF NO ENTER: NONE. *
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LIST CURRENT MEDICATIONS YOU ARE TAKING. IF YOU DO NOT TAKE ANY MEDICATIONS ENTER: NONE. *
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LIST ANY KNOWN ALLERGIES WITH MEDICATIONS AND/OR ENVIRNOMENT. IF YOU DO NOT HAVE ANY ALLERGIES ENTER: NONE. *
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PLEASE CHECK ALL THAT APPLY: MUSCULOSKELETAL *
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PLEASE CHECK ALL THAT APPLY: CIRCULATORY *
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PLEASE CHECK ALL THAT APPLY: RESPIRATORY *
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PLEASE CHECK ALL THAT APPLY: NERVOUS SYSTEM *
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PLEASE CHECK ALL THAT APPLY: REPRODUCTIVE *
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PLEASE CHECK ALL THAT APPLY: SKIN *
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PLEASE CHECK ALL THAT APPLY: DIGESTIVE *
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PLEASE CHECK ALL THAT APPLY: OTHER *
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CLIENT AGREEMENT/CONTRACT FOR CARE: It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage, bodywork and/or energy work. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions plan based upon the information provided by my massage therapist. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his/her skills and knowledge. I hereby agree to the terms explained above in the Client Agreement/Contract for Care. *
Please type your full name as a signature. *
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