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140 N 8th St, Lincoln NE 68508 Lower Level, Apothecary Building Name: ________________________________ Telephone: (Home) ____________________________ Address: _____________________________________ (Cell) ____________________________ City, State, Zip: ________________________________ Birth Date: _______________________ Your Occupation: _____________________________ Employer: _____________________________ Emergency Contact: _____________________________ Phone: ___________________________ Email: _________________________________Referred by: ____________________________________ How did you hear about us? Internet Friend Google Other_____________________ First Professional Massage? : (circle) Yes No If yes, how frequently do you have massage: _____________________________________________________________________________________ Are you presently under physician or chiropractic care? Yes No Are you currently taking a prescribed medication? Yes No If yes, please list the name of medication and condition for which medication is prescribed: _____________________________________________________________________________________ _____________________________________________________________________________________ List any accidents/injuries/surgeries: when they occurred and treatment received and if any lingering effects please explain: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you been pregnant or had surgery in the last 4 months? Yes No Have you been hospitalized in the last 4 months? Yes No Please list any allergies you may have: _____________________________________________________ What treatment are you receiving today? ___________________________________________________ Please circle the area(s) in which you prefer additional massage: Scalp, neck, face, shoulders, low back, upper back, buttocks, upper leg, lower leg, feet, hands Client History (helps determine treatment options): Please put a P for previous and C for current, leave blank if doesn’t apply: __Allergies affecting: __Facial/Body skin __Nose/Sinuses __Eyes __Stomach/Gut __Anxiety/Panic Attacks __Arthritis __Asthma __Athlete’s Foot __Birth Control __Blood Clots/Phlebitis __Blood Thinner __Breathing Problems __Cancer ____________ __Fatigue/Chronic Fatigue __Chronic Headaches __Chronic Pain in: ______________ __Claustrophobia __Cysts/Lipomas __Depression __Diabetes __Disc Condition __Dislocations __Dizziness/ Vertigo __Dental bridge/braces __Other medical condition not listed: __Eczema/Dermatitis __Epilepsy __Fever __Fibromyalgia __Gout in ___________ __Grieving __Hearing problems __Heat sensitivity __High Stress __HIV/AIDS __Heart Problems: ________ __Hepatitis __High Blood Pressure __Hypothyroidism __Impetigo __Infection ___________ __Infectious Disease ______ __Inflammation __________ __Kidney Disease/problems __Low Blood Pressure __Lupus __Migraines __Muscle/Joint Pain __Nausea/Fainting spells __Numbness___________ __On computer more than 2hrs/day # of hrs. ______ __Orthopedic pins or plates __Osteoporosis __Pacemaker __Plantar Fascitis __Pneumonia __Poor Sleep/ Insomnia __Pregnant __Psoriasis __Scoliosis __Seizures/Epilepsy __Sensitive Skin __Sinusitis __Skin Cancer/Disease __Spinal Cord Injury __Strains/Sprains __Stroke __Tendonitis __Tension/Stress __TMJ __Varicose Veins __Vision Problems/Contacts __Whiplash___________ ______________________________________________________ Consent for Therapy: I as a client agree to provide complete and accurate health information and notice of health changes. The above information is accurate. I understand that the massage is NOT sexually oriented in any way and that any illicit or suggestive remarks or behavior will result in immediate termination of the session. I understand that Massage Therapists do not diagnose disease or prescribe drugs and they are not a substitute for medical care. I understand that by signing this form, I give my consent to receive the treatment discussed. I have read this form and hereby freely give my permission to be massaged. I understand that a missed appointment might incur charges that I must pay. Client Signature: ________________________________________ Date: ________________________
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