MASSAGE & BODYWORK CLIENT HEALTH INFORMATION
Name: _____________________________________
Date: _________________
Home Address: ________________________________City: ________________________ State: ______ Zip: ___________
Telephone: ____________________________ E-Mail: ________________________________________
Date of Birth: _____/_____/_____ Age: ______ Height: _____________ Weight:_____________
Referral from: _____________ If no referral, how did you hear about us: ___________________________
Occupation: ________________________ Emergency Contact: _________________________ Telephone:
___________________
Are you pregnant or trying to get pregnant? _______ If so, how far along are you? _____________
List any medications you are now taking, the condition associated with it, and the respective doses:
_____________________________________ _____________________________________
What is your reason for bodywork today?
_______________________________________________________________________
PLEASE CIRCLE IF YOU HAVE / HAD ANY OF THE FOLLOWING CONDITION
Swelling
Allergies
Digestive Conditions (e.g. Crohn's, IBS)
Neurological (e.g. MS, Parkinson's, Chronic Pain)
Bruise Easily
Broken bones
Gas / Bloating / Constipation
Epilepsy / Seizures
Sensitive to Touch or Pressure
Diabetes
Kidney Disease / Infection
Headaches / Migraines
High / Low Blood Pressure If so is it controlled with meds?
Endocrine / Thyroid Conditions
Arthritis (Rheumatoid, Osteoarthritis, Psoriatic Arthritis)
Dizziness / Ringing in your Ears
Stroke or Heart Attack
Depression / Anxiety
Osteoporosis, Degenerative Disc / Spine
Numbing / Tingling
Varicose Veins
Memory Loss
Shunt / Pacemaker
Joint/ Muscle Pain
Shortness of Breath / Asthma
Cancer
Scoliosis
Other
If yes, please explain: ____________________________________________________________________________________
NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to
ensure client safety.
CONSENT FOR TREATMENT
A mixture of massage techniques including effleurage, petrissage, stretching, ART, Myofascial Release, and Trigger point work will be applied
during the treatment. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure
and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be constructed as a substitute for
medical examination, diagnosis, or treatment and that I should see a physician for any mental or physical ailment I am aware of. I understand
that nothing said in the course of the session given should be constructed as such. Because massage/bodywork should not be performed under
certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the
practitioner updated as to any changes in my medical profile and understand that there should be no liability on the practitioners part should I fail
to do so. I release pre-designated information to be shared with my other medical and well being specialists to aid in my treatment. Draping will
be used during the session, unless otherwise agreed upon by both client and therapist. At Fusion we do not perform massage without proper
draping. No massage of the breast tissue of female clients will be performed during the session without the written consent of the client. I also
understand that any illicit sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be
liable for the full payment of the scheduled appointment. I understand all of this and give my consent to receive care.
Client signature:____________________________________________________ Date: __________________
Parent or Guardian (in case of minor): __________________________________________________________
Therapist signature: _________________________________________________ Date: __________________
SELF-CARE RELEASE
-Have you consulted your doctor regarding your ability to use the far infrared sauna? Yes ( ) No ( ) If no it is recommended
that you talk with your doctor before using the infrared sauna.
-The use of drugs, medications, or alcohol prior or during the sauna session may lead to dizziness or unconsciousness.
-No one under the age of 18 is permitted in the far infrared sauna unless accompanied by a supervising adult.
-Older patients should consult their physician before using the infrared sauna.
-Discontinue the use of the sauna and/or jade massage table if you feel light-headed, dizzy or heat exhausted
SELF-CARE CONSENT FORM:
-Sauna sessions should be limited to no more that 30 minutes and temperatures must stay below 150 degrees Fahrenheit.
Jade table sessions should be limited to 20 minutes.
-It is always important to maintain proper hydration levels during far infrared and jade therapy.
-Please consult you physician if you are in doubt regarding your ability to use the far infrared sauna or jade table for health
reasons.
SELF-CARE ACKNOWLEDGEMENT:
I acknowledge and voluntarily assume the risk of injury, accident or death, which may arise from the use of the self-care
area. I and any of my heirs, executors, representatives or assigns hereby release all claims or liabilities for personal injury
or property damages of any kind sustained while on the premises, during the use of the self-care area and from any
advice provided by an employee, independent contractor or any representative. I agree that this Application and Waiver is
in effect for all self-care sessions and will not expire unless specifically requested by either party.
Signature: ______________________________________________________________________
Date: _____________________________
Version 4- Rev. 6/16/15