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RELIEF | RESTORE | RECOVERY

REJUVENATE | RELAX

Therapeutic Massage Therapy

To Schedule An Appointment

Text : 949.656.9429

PainRelief159@gmail.com

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To register to our Massage & Manual Therapy please fill out the following medical form

HEALTH Information FORM

A: Client Information

First Name

Email Address

Mobile Phone

Home Phone

Address

Emergency Contact Name

Last Name

Date of Birth

Physician's Name

Physician's Phone

OCCUPATION

Emergency Phone

B : Health Informations (Past or Current, Dates, Any Treatments)

Reason for Initial Visit

How would you rate your general health? *

Excellent

Good

Fair

Poor

How would you described your Stress Level? *

0 No Stress

1

2

3

4

5

6

7

8

9

10 Worst Stress Imaginable

How would you described your PAIN Level? *

0 No Pain

1

2

3

4

5

6

7

8

9

10 Worst Pain Imaginable

List current Medications & the Conditions that you are treating.

List any accidents, injuries, fall, fracture, sprain or surgeries (including dates)

Have you had Massage Theray or Manual Therapy before? *

No

Yes

What types of Massage Therapy or Manual Therapy you had before? (Please describe)

C : Health Information Checklists

HEAD and NECK

Headaches

Migraines

Vertigo

Dizziness

Ringing in Ears

Hearing loss

Vision problems

Vision loss

Others

For Others Head & Neck, Please describe;

NERVOUS SYSTEM

Sensory Loss / Change

Sciatica

Seizures

Numbeness / Tingling

Eplilepsy

Multiple Sclerosis

For Others Nervous System, Please describe;

MUSCULOSKELETAL SYSTEM : (Muscles, Bones, Joints)

Arthritis

Osteoporosis

Bursitis

Tendonitis

Jaw pain (TMJ)

Family history of Arthritis

Pins/ Plates/ Wires / Artificial joint

Disk problems

Knee problems

Pain

Stiffness

Tension

Tendency to Cramp

For Others Musculoskeletal System, Please describe;

OTHER CONDITIONS

Cancer

Diabetes

Unexplained weight loss

Fibromyalgia

Depression

Anxiety

Psychiatric disorder

Digestive conditions

Chronic fatigue syndrome

RESPIRATORY

Astha

Chronic cough

Short of breath

Exphysema

Frequestcolds

Bronchitis

Sinusitis

Smoker

Family history of respiratory difficulties

Others

For Others Respiratory, Please describe;

CARDIOVASCULAR SYSTEM

High blood pressure

Low blood pressure

High cholesterol

Heart attack

Heart disease

Stroke or TIA (transient ichhemic attack)

Poor circulation

Hemophillia

Phlebitis (inflamed vein)

Varicose veins

Pacemaker

Chronic congestive heart failure

Deep Vein Thrombrosis (blood clot)

Atherosclerosis or Hardened arteries

Pulmonary embolism

Angina

Heart arrhythmia

Family history of Cardiovascular problems

SKIN & INFECTIONS

Hepatitis

Herpes

Lyme disease

HIV / AIDS

Tuberculosis

Infectious skin conditions

For Others Skin & Infections, Please describe;

REPRODUCTIVE SYSTEM

Pregnant

Give birth

Gynecological problems

For Others Reproductive System, Please describe;

For Others Conditions, Please describe;

Please read the following, initial and sign below:

It is my choice to receive Massage Therapy and Manual Therapy. I am aware of the benefits and risks of Massage Therapy and Manual Thereapy and give my consent for Massage Therapy and Manual Therapy. I understand that there is no implied or stated guarantee of effectiveness of individual techniques or series of appointments. I ackhowledge that Massage Therapy and Manual Therapy is not a substitute for medical care, medical eaxmination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the verious care providers involved in my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my resposibility to confirm the exact details of my coverage.

Be aware that our Certified Massage Therapists have wide variety of Advanced Training. Techniques to used include Neuromuscular therapy, Myofascial Release, Trigger Point, Medical Thai Acupressure Therapy, Traditional Thai Massage, Manual Lymptic Drainage, Soft Tissue Manipulation, Visceral manipulation, Craniosacral, Oncology, Pre-Postnatal, Acupressure, Swedish, Cupping, Hot stone, Muscle Energy Techniques, Range of Motion, Stretching, Hot or Cold applications, Eastern and Western Massage therapy modalities.

I will respect the time of my Massage Therapist(s) and other clients. I agree to come to my scheduled appointment promptly, barring any unforeseen emergency. I understand that if I cancel later than 24 hours perior to my appointment, I agree to pay "HALF" the cost of my appointment. If I "NO SHOW", I agree to pay the "FULL" price of the appointment.

Client Signature and Initials

Today's Date

Thank you.Your information has been successful submitting. Now you can schedule your appointment byText / Call 949-656-9429We will get back to you within 24 hours.

© 2020 by PainRelief 159

To Schedule An Appointment

Call 949.656.9429

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