Dixie's Sunrise Massage Therapy

Helping you, help yourself to better health

Client Forms


 

 

Dixie’s Sunrise Massage Therapy

CLIENT INFORMATION:

Name_____________________________________ Email____________________________

Address_____________________________________________________________________

Telephone (h)_______________    (w)__________________ (c)________________________

OCCUPATION______________________   EMPLOYER__________________________

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

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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                                

Allergies: ______________________________________________________________________

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 ___

                             RELEASE STATEMENT

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: ___________________________

 

 

                                                           

 

 

 

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