Client Form
Name:
Address:
Home Phone:
E-Mail:
Date of Birth:
Marital Status:
Referred by:
Occupation:
Physician:
In Emergency Notify:
Date:
Cell phone:
Age:
Phone:
Phone:
Client Assessment Form
An accurate health history is important to ensure that it is safe for you to receive treatment. If your
health status changes in the future, please let us know. All information gathered for treatments is
confidential. You will be asked to provide written authorization for release of any information.
Cancelation Policy
Please note that a 24 hours advance notice is required for cancellation of all appointments; otherwise
you will be charged $50.00 for the missed visit.
Are you currently taking any medications? (Y/N)
Name of Medication
Reason for taking
For how long
Med 1
Med 2
Med 3
Past Injury or Surgeries, Painful or sensitive scars:
Describe
Injury/Surgery
Injury/Surgery
Injury/Surgery
When
Location of sensitive scars
Body Map
Where in the body are you experiencing symptoms or pain?
o
o
o
o
o
o
Head
Neck
Chest
Upper Back
Lower Back
Shoulder
o
o
o
o
o
o
Muscles
Arms
Hands
Abdomen
Urinary
Genitals
o
o
o
o
o
o
Skin
Hip
Knee
Legs
Foot
Ankle
Please describe your main concerns:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please mark areas of Pain (X), Discomfort (D) or tension (T)
History
Health History
Check the appropriate box if you have or have had recent problems with any of the following:
Major Conditions
o Arthritis
o Bursitis
o Headaches
o Swollen Joints
o Fibromyalgia
o High Blood
Pressure
o Low Blood
Pressure
o Poor Circulation
o
o
o
o
o
o
o
o
Anemia
Stroke
Seizures /
Convulsions
Heart
Conditions
Constipation
Sinus / Allergies
Hematomas
Phlebitis
o
o
o
o
o
o
o
Skin and Hair
o Rashes
o Ulceration
o Hives/Allergic Dermatitis
s
skin
o Loss of Hair
o Itchy
o Eczema/Psoriasis
o Skin
o Acne
o Change in Skin/Hair
Discoloration
Texture
Throat, Nose Ears, Eyes, Head
o Dizziness
o Difficulty swallowing
o Eye pain
o Sinus
o Recurrent sore throat/Colds
o Jaw
Infection
clicks/locks
Earaches
Spots
in
front
of
eyes
Vision
o
o
o Blurred
o Ringing in
o Sores on lips/tongue
o Cataracts
ears hearing
o Poor
o Dental problems
o Grinding Teeth
Respiratory
o Coughing Blood
o Cough/ Wheezing
o Pneumonia
Cardiovascular and Circulation
o Chest pain or
pressure
o Irregular Heart beat
o Palpitations
o Easy to faint
o Cold hands/Feet
o Swelling of
hands/feet
o Blood Clotting
problem
o Vein Inflammation
o Shortness of breath
o
o
Asthma
Pain with deep
inhalation
o
Varicose/Spider
veins
Pressure in chest
Anemia
Low blood pressure
Spontaneous
sweating
Dizziness
Reynaud’s Disease
High blood
pressure
Elevated Blood
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Varicose Veins
Cancer
Skin Conditions
Pregnant?
____# of
months
Menstrual Pain
Warts
Athlete’s Feet
o Face Flushing
o Weak or ridged
nails Infection
o Fungal
o
o
o
o
o
Headaches
Migraines
Night
Blindness
Facial
pain
TMJ
Emphysema
Bronchitis
Chronic Cough
Cholesterol
Cold hands and
feet
Stroke
Heart Condition
– please explain
_____________
_____________
_____________
_____________
_____________
Digestion/Gastrointestinal
o Nausea
o Gas
o Indigestion
o Bleeding
o Bloating
o Significant thirst
o
o
o
o
o
o
Vomiting
Gum
inflammation
Bad breath
Hernia
Acid
reflux/GERD
IBS/Crohn’s
o
o
o
o
o
o
Chronic Diarrhea
Ulcer
Tooth implants
Loose stools
Excessive appetite
Food allergy/tolerance
aallergies/intolerance
o
o
o
o
o
Genito-Urinary
o Genital Herpes
o Infections
o Impotence
o Prostatitis
o Excessive libido
o Night urination
o
o
o
o
o
o
Kidney stones
Sores on genitals
inflammation
Pain
in testicles
Decreased libido
Blood in urine
reflux/GERD
Scanty flow
o
o
o
o
o
o
Urinary tract infection
Pain in urination
Unable to hold urine
Premature ejaculation
Burning urination
Dribbling after urination
aallergies/intolerance
o Urgent urination
Reproductive
o Difficult/Painful
Intercourse
o Ovarian Cysts
o Age of first
menstruation:
o Last menstruation
o Vaginal discharge
o Endometriosis
o Uterine Fibroids
o PMS
o Abnormal Pregnancies(Reason):
o
o
o
o
o
Date of last
PAP/Pelvic
Irregular
menstruation
Fibrocystic breast
tissue
Pregnancies (How
many)
Painful menstruation
o
o
o
o
Constipation
Blood in stool
Hemorrhoids
Abdominal cramps
pain/cramps
Poor
appetite
Polycystic Ovarian
Disease
Caesarean births
(How many)
Infertility
Abortions (When)
Do you practice birth control?
o No
o Yes
What type? ___________________ Since when? _________________
Neurological/Psychological
o Seizures
o Loss of Balance
o Vertigo/Dizziness
o Areas of numbness
o Lack of coordination
o Poor memory
o Concussion
o Vivid dreams
o
o
o
o
o
Easily susceptible to
stress
Anxiety/Panic
Attacks
Bad
Temper/Irritability
Depression
Waking up at night
Have you ever been treated for emotional problems?
Have you ever considered or attempted suicide?
Have you ever been treated for substance abuse?
o
o
o
o
o
Seasonal Affective
Disorder
Nervousness
ADD/ADHD
Bi-Polar Disorder
Poor Sleep
Health History Declaration
For Your Information
An accurate health history is important to ensure that it is safe for you to receive treatment, if your health
status changes in the future please be sure to let us know.
This form must be updated annually.
All information gathered in this form is kept confidential and will not be released unless the client issues a
written consent, allowing the practitioner to release the information.
I hereby declare that the information that I have given above regarding my health condition is accurate
and true to the best of my knowledge.
Name: ____________________ Signature: ________________________ Date: _______________
(Please print)
Informed Consent to Treatment
Prior to any massage or sound healing your choice of an Infrared Sauna or Softub hot tub is included. Although
the utmost care will be taken to ensure safety and comfort for our clients/patients, in the event of injury at
Enchanted Healing Center, Colleen Linseman or Wynne Ross or Enchanted Healing Center will not be held liable
for any reason.
Please be aware that when using the following treatment modalities: Shiatsu Therapy, Deep Tissue Massage,
Swedish Massage, Reflexology Massage, Aromatherapy Massage, Sound Healings or Pedicure/Manicure, it can be
that some very rare reactions may occur and may include bruising (hematoma), fainting, dizziness, nausea,
pneumothorax, risk of infection.
Each session may intuitively include chakra purification smudging with gifted sacred eagle feathers. Healing
herbs such as palo santo, agua de florida spirit water from Peru, copal, sweetgrass, sage, aromatherapy oils,
crystal Amega wand and tonal, tribal vibrational sounds, drumming, chanting, are some of the elements
Colleen may be called to use during your healing session. If at any time you are uncomfortable with the
technique being used, you can tell Colleen and you can also stop the treatment at any time.
Massage therapy involves the manipulation of the soft tissues of the body, skin, muscle, ligaments and
connective tissues, using techniques to produce therapeutic and healing results. With massage therapy, the
client disrobes to their comfort level, and lies on a table between two sheets. Only the areas of the body being
directly treated are uncovered at one time. If at any time you are uncomfortable with the pressure or technique
being used, you can tell Colleen (i.e. to decrease or increase pressure, irritating, etc.).
Please be aware that you may request to stop or alter the treatment at any time and for any reason and the therapist
will comply with your wishes.
I have read the above and give consent for treatment.
Name: ____________________ Signature: ________________________ Date: _______________
(Please print)