Health Intake
Liberation Therapies, Kimberly Hoflich MT HHP CA#32143
Full Legal Name: *
Your complete privacy is protected by HIPPA laws
Your answer
Thank you for booking your massage!
To provide you with The Best service possible, it is imperative this form is filled out completely and accurately. Thank you!
E-mail Address
Your answer
Best Phone Number *
Your answer
Date of Birth *
Your answer
Emergency Contact, Name & Phone Number *
Your answer
If you have any of the following conditions, please list them in the box below. If necessary, please provide any explanations: *
Allergies: Food or Hay Fever, Aneurysm, Arthritis, Back Pain, Bleeding/ Bruising easily, Blood Pressure Issues (uncontrolled), Boils, Bursitis, Cancer/Radiation, Cellulitis, Contagious Diseases(s), Diabetes, Dentures, Dizziness, Drug or Alcohol abuse, Extremely Hungry or Full at the time of massage, Fever, Fibromyalgia, Guillain-Barre syndrome, Headaches (NOT Migraines), Heart Condition (pacemaker, stent, or shunt or anything, similar, related or unusual in nature), Hernia, Hemorrhoids, IBS, Implants of any kind in the last 9 months, Joint Problems, Kidney Disorders/Problems, Lupus, Migraines, Muscle: Strain/Sprain, Tension, Soreness, Neck Pain, Numbness or Stabbing Pain, Neuropathy, Osteoporosis, Phlebitis/Blood Clots, Pregnancy (current), Recent Surgery, Respiratory Problems, Rib or any other bone fracture, Sciatic Nerve Problems, Seizures/Epilepsy, Shell Fish Allergy, Sinus Problems, Skin Cancer, Skin Condition/Disorder/Disease, Skin lesions, Skin Rash, Spine Curvature (such as scoliosis or lordosis or anything similar or unusual in nature), Steroid Use (Topical, Ingested or Injected), Thrombosis, Tuberculosis, Varicose Veins, Vertebral Disc Problems, Warts - Please include any recent surgeries or procedures, recent injuries, open wounds, rashes, cancers or anything unusual or contagious ***If none, type "none" in the box below:
Your answer
Medications, list any and all, prescribed or over the counter, and what they are used for: *
If none, type "none"
Your answer
Please list any other conditions, disorders, diseases or concerns you have that are not listed on this form here: *
If none, type "none"
Your answer
Broken bones, injuries or accidents in the past 3 years? *
Has your Doctor or Health Care Provider from who you seek medical advice, advised you against receiving a massage? *
If there is anything else your Massage Therapist needs to know, please explain below:
Your answer
WOMEN: Are you trying to conceive or are you pregnant?
WOMEN: If you are pregnant, how far along are you?
Your answer
WOMEN: Do you experience unusual flow or heavy cramping:
Yes, No or Sometimes Please explain if necessary:
Your answer
Please read the following and sign: A referral from your primary care provider may be required prior to services being provided. I understand the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. I understand will be receiving a massage service which is not intended as physical therapy treatment under the direction of a doctor or health care professional. If I experience any pain or discomfort during the session I will immediately inform the practitioner so that the pressure may be adjusted to my level of comfort. I further understand that massage should not be used as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor an other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session should be construed as such. I affirm I have stated all my know medical conditions, answered all questions completely, honestly and agree to keep the practitioner updated to any changes in my medical profile and understand there shall be no liability on the practitioners behalf if I forget to do so. It is understood that any elicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, legal charges will be filed and I will be liable for full payment of the appointment. 48 hour cancellation/reschedule fee is understood. Understanding all of this, I give my consent to receive care. *
Please indicate acceptance of these conditions by typing your full legal name in the box below:
Your answer
DEEP = Anything more than light pressure. “DEEP” clients, please read the following, and e-sign below: I am requesting more than light pressure. If the pressure is ever outside my comfort, I completely understand it is my responsibility to inform Kimberly immediately. It is likely to experience sinus congestion for a short period. If you encounter other possible side effects such as stiffness and soreness (especially if you’re dehydrated), skin irritations, marks, headaches, bruises or any injury or condition, I will not hold, Kimberly Hoflich, the property owner, or the company liable. I understand that it is best not to sit in a hard chair, lift anything over 35 lbs., not to participate in contact sports or twisting (ie:golf, baseball), no heavy alcohol consumption for 24-48 hours. I understand it is good to drink a lot of water, passively stretch, wear support if needed and treat myself to moist heat. (Although some clients ask for deep compression, I, Kimberly Hoflich, prefer to keep the compression at the therapeutic level that I feel comfortable with. Your comfort and safety are my number one concern. If you request for more compression on a higher level than that of the therapeutic range I am delivering, I, Kimberly Hoflich, nor the property owner, will not be held responsible for aggravating a condition that may, or may not, already be present.) I understand the entirety of this section and am requesting more than light pressure. *
If you are requesting ANYTHING MORE THAN LIGHT PRESSURE massage, please indicate acceptance of these conditions by typing your first and last name below. If you're requesting ONLY light pressure, please type "light"
Your answer
CONSENT TO TREATMENT OF A MINOR: By my e-signature below, I authorize Kimberly Hoflich to administer massage/bodywork to my child or dependent. I affirm I have stated all my child or depedents known medical conditions, answered all questions honestly and agree to keep the practitioner updated as to any changes in their medical profile and understand there shall be no liability on the practitioners behalf if I forget to do so.
Type the full legal name of your dependent and your full legal name in the box below. Please be sure to input BOTH of your full names.
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms