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Download Sweet Sage Massage Health History and Waiver Form Name: Home
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Sweet Sage Massage Health History and Waiver Form Name:__________________________________________________________Male_____Female_____Age______ Home Ph#___________________________Cell Ph#______________________Work Ph#________________________ Mailing address________________________________________________________________________________________ Occupation:__________________________________Email____________________________________________________ Have you had any surgeries, accidents, or traumatic experiences in the past 5 years? ________________________________________________________________________________________________________ Have you been under a Doctors care within the past 12 months? If so, for what reason? ________________________________________________________________________________________________________ Medications you currently take and for what purpose? _________________________________________________________________________________________________________ Do I have permission to contact your doctor? (Serious conditions only) Doctors name and contact information: ____________________________________________________________ __________________________________________________________________________________________________________ Do you have any infectious diseases or conditions? If so please explain:__________________________ ___________________________________________________________________________________________________________ Are you Pregnant?______________ How far along?____________________ ___Neck ___High Blood Pressure ___Shoulders ___Low Blood Pressure ___Upper back ___Heart Condition ___Mid Back ___Varicose Veins ___Lower Back ___Stroke ___Elbow ___Pacemaker ___Wrist/Hand ___Heart Disease ___Hip ___Dizziness/Vertigo ___Knee ___Seizures ___Ankle/Foot ___Clotting Disorder ___Tendonitis ___Lymphedema ___Bursitis ___Family History of above ___Arthritis ___Yes ___No ___Spasms/Cramps ___Scoliosis ___Bone/Joint disease ___Broken/Fractured Bones Broken/ ___Headaches ___Migraines ___Head Injury ___Vision Loss ___Vision Problems ___Hearing Loss ___TMJ ___Cancer ___Diabetes ___Lupus ___Rheumatoid Arthritis ___Fibromyalgia ___Chronic Fatigue ___Epilepsy ___Allergies ___Anxiety ___Athletes Foot ___Depression ___Warts ___Sleep disturbance ___Rash ___Loss of sensation, ___Psoriasis _____________Where? ___Eczema _____________Other? ___Infectious Disease As with all other forms of treatments, therapeutic massage may have some unwanted side effects of which you should be aware. Occasionally, during or after a treatment discomfort may occur temporarily until muscle tension releases. Following treatment some people may experience tenderness, aching, or headaches. Our therapists take every precaution to minimize these occurrences. Please follow the recommendations that your therapist provides you. Provincial privacy act regulations require that you are informed as to why your personal information is being obtained from you. Your information is being gathered for purposes of generating a confidential medical record that will remain secured. In the event that a request is received from an outside party for a copy of your medical information, release of your information will occur only upon written consent. I have completed this health form to the best of my knowledge and will inform my therapist of any changes that occur in my health. I do understand that massage therapy and bodywork services are a therapeutic aid and are non-sexual services. I do understand that massage therapy and bodywork is not substitute for medical examination and /or diagnosis and that it is recommended that I see a Doctor for any physical ailment or other issues that I may have. I am aware that in the event my assessment reveals a condition suggestive to contraindication of massage therapy or any other treatments, that it would be unsafe to treat me. I release my therapist from any and all liability for any problems arising from the treatment as a result of information I have failed to provide or have provide incorrectly to my therapist. I will not hold Sweet Sage of Cochrane, AB or Pamela Paul, RMT/OWNER or any other therapist from Sweet Sage Massage responsible for any adverse effect on my health that this treatment might have. Payment Policy: I agree to pay a cancellation fee if I do not give 12 hours notice to cancel my appointment. I ______________________________________ (patients name) acknowledge that Pamela Paul reserves the right to refuse treatment to anybody at anytime. Guest or Guardian signature_______________________________________________________________________ How did you hear about Sweet Sage Massage?_______________________________________________________ Please visit our website @ www.SweetSageMassage.com for our specials and updates.
