Original Date:
Dates Revised:
AR THERAPEUTIC MASSAGE INSTITUTE & SPA
All questions contained in this questionnaire are strictly confidential and will be become part of your record at ARTMIS.
They will be shared ONLY with written permission of the below signed responsible party.
Name
M
(Last, First, M.I.):
Marital status:
Single
Partnered
Have you ever had a massage with us?
Married
Separated
Yes
No
F
Divorced
DOB:
Widowed
Date of last massage?
How did you hear about us?
Occupation?
Address:
City, State, Zip:
Email:
Phone:
Emergency Contact and Phone Number:
PERSONAL HEALTH HISTORY
List any medical problems that other doctors have diagnosed
Past surgeries or orthopedic problems that may be relevant to your massage
Year
Reason
Area
Are you currently pregnant, and if so, how many months?
Yes
No
MOs________________
Prescribed drugs and over-the-counter drugs, such as vitamins, herbs and inhalers
Name the Drug
Yes
No
Reason for Drug
Controls problem?
Yes
No
Yes
No
Yes
No
Yes
No
Allergies?
Substance
General Current Health:
Reaction You Had
Excellent
Good
Average
Less than Average
Poor
ARKANSAS THERAPEUTIC MASSAGE INSTITUTE & SPA
Depict how you are feeling today by drawing a circle on the
figures representing the size and shape of the following
symptoms. Place the letter representing the symptoms in or
near the circle:
P = pain, ache or tenderness
S = Stiffness in the joint or muscle
Please rate your current complaint BEFORE the massage on a
scale of 0-10 scale, with 0 being no complaint, and 10 being
unbearable:
0---1---2---3---4---5---6---7---8---9---10 Area:_____________
0---1---2---3---4---5---6---7---8---9---10 Area:_____________
0---1---2---3---4---5---6---7---8---9---10 Area:_____________
1.
I understand that clients under the age of 17 must be
accompanied by a parent or legal guardian during the entire
session. Informed written consent must be provided by parent or
legal guardian for any client under the age of 17.
2.
I understand that the session will include primarily Swedish massage techniques on the back, buttock area, legs, face, neck, shoulders, arms,
hands and feet. I understand that I may verbalize a decision to the therapist to focus on a specific area at the detriment of another area to
stay within time restraints, to improve my benefit from the session. This will be addressed by the therapist/student during initial interview.
3.
I understand that appropriate draping will be used during the session – only the area being worked on will be uncovered. At no time will the
genitals be exposed or manipulated. Buttocks will only be exposed with verbal permission from the client. Breast massage will only be
performed in accordance with below guidelines (4).
4.
Massage of breast tissue will only be for therapeutic purpose for scar reduction, lymphatic edema or myofascial restriction. Any other reason
for exposure or manipulation of breast soft tissue will be accompanied by a written prescription from a medical practitioner and ALL breast
tissue manipulation will be restricted to medically diagnosed conditions and performed ONLY by personnel with 48 hours of special education
in appropriate massage technique (lymphatic breast massage, myofascial breast massage, or breast oncology massage).
5.
If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be
adjusted to my level of comfort. I understand that if I feel uncomfortable during my session I will immediately stop the technique or session,
dependent on my judgment.
6.
I understand that the massage therapy I receive from the massage therapist/student is for purposes of stress reduction, muscle spasm/tension
reduction, circulation improvement and to enhance my overall wellness. If my reasons for seeking massage therapy change from those
reasons, I understand that it is my responsibility to inform the therapist/student.
7.
I understand that the massage therapist does not prescribe medications, or perform or prescribe medical treatment, except as directed by a
licensed medical practitioner. I understand the massage therapist does not provide medical examination or diagnosis.
8.
I take it upon myself to seek proper medical attention from a medical practitioner for any ailment, physical or mental, that I may have.
9.
I understand the purpose of this massage is to provide benefits as listed in (5) and any sexual remarks or advances will terminate the session
and I will be liable for payment of the scheduled treatment.
10. Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical
conditions truthfully.
11. I understand that if I arrived late, the massage will terminate at the originally scheduled time so the client following me is not penalized.
Client Signature______________________________________________________________________________________Date:_______________
Client Signature for Validation of Breast Massage as noted in accordance with (4)_____________________________________________________
Parent or Guardian Signature:______________________________________________________________________________________________
Therapist/Student Signature:_______________________________________________________________________________________________