CLIENT HEALTH INFORMATION SHEET PERSONAL DATA: Name: ________________________________ Date: ______________________________ Birthday: ______________________________ Phone (home):_______________________ Address: _______________________________ Phone (cell): ________________________ City/State/Zip: ________________________________________________________________ Primary Health Care Provider: _____________________ Phone: ______________________ Permission to consult with primary provider? _______ Yes _______ No Who referred you to this office? __________________________________________________ Advertisement: _______ Sign: _______ Other: _______ MASSAGE HISTORY/TREATMENT INFORMATION * Have you ever received a professional massage? _____ Yes _____ No * Preferred massage treatment product. ____ Lotion ____ Oil ____ Aromatherapy * What are your intentions/expectations for this visit? __________________________ ______________________________________________________________________ * What type of pressure do you prefer? _____ Light _____ Medium _____ Deep * Please check the areas of your body that you give permission to receive massage: __ Back __ Legs __ Arms __ Neck __ Head __ Face __ Buttocks __ Abdomen CURRENT MAJOR COMPLAINT INFORMATION (If you do not have current health concerns, please go to health history section) * Present symptoms: What is your major complaint or condition that you want to improve? ______________________________________________________________ _______________________________________________________________________ * When did you first notice major complaints? _________________________________ * What activities aggravate the condition? ____________________________________ * What activities alleviate the condition? _____________________________________ * Is this condition getting progressively worse? _____ Yes _____ No Please explain __________________________________________________________ * Does this condition interfere with: Work? ___ Yes ___ No Sleep? ___ Yes ___ No Daily routine? ___Yes ___ No Please explain: _________________________________________________________ * What have you done to get relief? __________________________________________ * Has there been a medical diagnosis? ___ Yes ___ No
If so, by whom? ________________________________________________________ Please explain __________________________________________________________ HEALTH HISTORY * Are you now under medical/therapeutic treatment? ___ Yes ___ No If yes, for what condition? _______________________________________________ * List any medications (including aspirin) and nutritional supplements you are taking: ______________________________________________________________________ * List stress reduction and exercise activities. Include frequency: _________________ ______________________________________________________________________ * Please list (date and description) any accidents or operations: ___________________ ______________________________________________________________________ MUSCULO-SKELETAL SKIN ___ Bone or joint disease ______________________ ___ Allergies __________________ ___ Tendonitis ______________________________ ___ Rashes ____________________ ___ Bursitis ________________________________ ___ Athlete’s foot _______________ ___ Broken/fractured bones ____________________ ___ Warts ____________________ ___ Arthritis ________________________________ ___ Other _____________________ ___ Sprains/strains ___________________________ ___ Low back,hip,leg pain _____________________ DIGESTIVE ___ Neck,shoulder,arm pain ____________________ ___ Constipation ___ Headaches/head injuries ___________________ ___ Gas/bloating ___ Spasms/cramps __________________________ ___ Diverticulitis ___ Jaw pain/ TMJ ___________________________ ___ Irritable bowel syndrome ____ ___ Lupus _________________________________ ___ Other _____________________ ___ Other __________________________________ CIRCULATORY NERVOUS SYSTEM ___ Heart condition __________________________ ___ Herpes/shingles ____________ ___ Varicose veins ___________________________ ___ Numbness/tingling __________ ___ Blood clots _____________________________ ___ Chronic pain _______________ ___ High blood pressure ______________________ ___ Fatigue ___________________ ___ Low blood pressure ______________________ ___ Sleep disorders _____________ ___ Lymphedema ___________________________ ___ Other ___ Breathing difficulty _______________________ ___ Sinus problems __________________________ REPRODUCTIVE ___ Allergies _______________________________ ___ Pregnant? Stage ____________ ___ Other __________________________________ ___ PMS _____________________ AUTO IMMUNE/INFECTIOUS DISEASE OTHER ___ Fibromyalgia ___________________________ ___ Cancer/tumors _____________ ___ Chronic fatigue _________________________ ___ Diabetes __________________ ___ Rheumatoid arthritis _____________________ ___ Eating disorders ____________ ___ Lupus ________________________________ ___ Depression ________________ ___ Epstien Barr ____________________________ ___ Drug/alcohol addiction _______ ___ Other _________________________________ ___ Nicotine/caffeine addiction ____ It is my choice to receive massage treatment. I realize that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. I agree to communicate with my practitioner any time that I feel like my well-being is being compromised.
I understand that massage practitioners do not diagnose illness, disease or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health. Signature: ____________________________________ Date: _______________________
Two-Tier Plan 2011 CIGNA Choosing the medication that is right for you offer an extensive list of brand and generic Choosing where to fill your medication should be easy, too. With over 60,000 pharmacies network, you will have convenient access to your medications – whether you pick them up, or Enclosed you will find a list of medications covered by your plan, in an easy-to-read fo
There are several benefits to using the Sunlighten sauna. Some of these include:DETOXIFICATION RELAXATION PAIN RELIEF WEIGHT LOSS LOWER BLOOD PRESSURE BETTER CIRCULATION SKIN PURIFICATIONSome cautions to be understood and followed for safe use of the Sunlighten sauna:1. Do not use if pregnant, have serious inflammation, a fever, a communicable disease, acute bleeding, or intoxicated. 2. The use of