Helping you, help yourself to better health
Dixie’s Sunrise Massage Therapy
Telephone (h)_______________ (w)__________________ (c)________________________
DATE OF BIRTH______________________ REFERRED BY ________________________
HAVE YOU HAD A PROFESSIONAL MASSAGE OR BODY TREATMENT BEFORE? ___YES ____NO
PRIMARY REASON FOR TREATMENT_________________________________________
AREAS THAT NEED ATTENTION _____________________________________________________________________________
HAVE YOU HAD AN INJURY OR SURGERY? _____YES ____ NO
IF YES, PLEASE DESCRIBE _________________________________________________________
HOW WOULD YOU DESCRIBE YOUR GENERAL HEALTH?
____Poor _____ Fair _____ Good _____ Excellent
HOW WOULD YOU DESCRIBE YOUR LIFESTYLE?
Dietary Habits ____________ Exercise Habits ____________
Rest/Stress Levels ____________________________________________________
Vitamins, Herbs & Medications __________________________________________
DO YOU TAKE IN HIGH AMOUNTS OF ANY OF THE FOLLOWING:
___Caffeine ___ Nicotine ___ Alcohol ___ Fast Food ___ Water
PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING:
___ Blood Clots ___ Arthritis
___ Diabetes ___ Circulatory Disorders
___Heart Disease ___ High Blood Pressure
___ Joint Disease ___ Low Blood Pressure
___ Skeletal Injuries ___ Hernia/Rupture
___ Skin Conditions ___ Varicose/Spider Viens
ARE YOU PREGNANT? ___ Yes ___ No HAVE SLINGS OR MESH? ___ Yes ___ No
PLEASE CHECK ANY CHRONIC CONDITIONS THAT YOU MAY BE HAVING:
___ Abdominal Pain ___ Chest Pain ___ Dizziness
___ Depression ___ Fatigue ___ Insomnia
___ Sinusitis ___ Migraine Headaches ___ Joint Pain
___ Headache ___ Constipation ___ Digestive Problems
Other: __________________________________________________________ _______________________________________________________________________
Do you have any spinal problems?___________________________________________
Please list any vertabre issues: ____________________________________________
IS THERE ANYTHING ELSE THAT WE SHOULD KNOW PRIOR TO YOUR TREATMENT?
Do you have computer implants such as a pacemaker, insulin pump or spinal stimulator?
YES ___ NO ___
I understand that all treatments at this facility are therapeutic in nature. I agree to notify the therapist of any physical discomfort or draping issues during the session.
This facility has provided me with information on MediCupping™ therapy. If I choose to experience this therapy in my treatment, I understand the effects and after-care recommendations. It has been explained to me that there is the possibility of a skin discoloration, or “cup kiss,” appearing as tissue is released. I am aware that a “cup kiss” is not a bruise and that it will dissipate within a few hours to a few days.
This facility and the therapist will not be held liable for indications that arise during or after the treatment, and I agree to notify the therapist if there is any discomfort during a session. I have stated all relevant physical conditions and will inform the therapist of any changes in my health.
SIGNATURE: ______________________________________ DATE: ___________________________