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Bodywork Client Record

Redemption/Voucher Code Name:_ _________________________________________ Birthday:______________________________________ Home Phone # Occupation ________________________________________________

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NOTES

Clinic Use Only

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Home Address:________________________________________________________________________ City: Cell Phone Number: Emergency Contact Name/Number:________________________________________________________ Email Address: ________________________________________________________________________ May I email you specials and updates every now and then? Have you had professional massage before? Yes / No Yes / No State: Zip:

If Yes, how often do you receive massage therapy?__________________________________________ Please list any allergies__________________________________________________________________ ____________________________________________________________________________________
PRACTITIONER REFUSED SERVICE: YES | NO

Please identify particular areas of the body you are experiencing tension, stiffness, pain and other discomforts? REASON:
SERVICE MENU/ADD-ONS
STESS MASSAGE DEEP TISSUE SHIATSU THAI MASSAGE CHI NEI TSANG MYSOFASCIAL RELEASE FOOT REFLEXOLOGY ACUPRESSURE AROMATHREAPY TUI NA CUPPING MOXIBUSTION GUA SHA QIGONG AURICULAR $90/50min $110/50min $110/50min $150/75min $110/50min $110/50min $110/50min $110/75min $110/50min $110/50min $65/30min $110/50min $110/50min $110/50min $65 /30min

Do you have any of the following today: [ ] Cold or Flu or Fever [ ] Are you pregnant? Due: [ ] Open cuts/sores [ ] Skin rash-where Medical History: Have you ever had/do you have any of the following : [ [ [ [ [ ] Diabetes ] AIDS/HIV ] Constipation ] Fibromyalgia Syndrome ]Chronic Fatigue Syndrome [ [ [ [ [ ] High / Low BP: ___________________________________________ ] Blood Clot/DVT [ ] Kidney Disease [ ] Heart Attack/MI ] Lupus/ Crohns / Lymes [ ] Stroke/CVA / TIA [ ] Allergies: ] Liver Disease [ ] Neuropathy/Numbness [ ] Other: ] Cancer/Tumor/Chemo [ ] Seizures

COMMUNITY ACUPRESSURE $50 initial $40 return ACUPUNCTURE & 30MIN MASSAGE $120/60min

_____________________________________________________________________________________ What are your goals/intentions for this massage session?_______________________________________ _____________________________________________________________________________________ List other therapies you currently receive: ___________________________________________________ Are you now under medical/therapeutic treatment? If Yes, please explain Please list Yes / No

Please list any medications you may be taking: ____________________________________________________________________________ Please list any surgeries you have had: __________________________________________________________________________________ Please list any additional comments regarding your health and well-being: _______________________________________________________

Bodywork Client Record

Redemption/Voucher Code ___________ I understand the promotional discount massage is offered either as a one- time experience or per limited use of its limited promotional offer. I understand that the massage I receive is provided for the basic purpose of relaxation and relief of stress, muscular tension and includes tissue manipulation with various tools (electrical vibration, pressure knobs, cupping, guasha, moxibustion, press pellets, aroma) and techniques of the practitioner to parts of my body including back, arms, head, legs, chest, shoulders and neck and may exclude face, feet, buttocks, and breast per practitioner policy and assessment. 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 further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I fail to do so. I understand massage is contraindicated for skin conditions such as rash, acne, irritable and local contagious skin conditions, open wounds and sores, decubitus ulcers, radiation sites (physician consent is needed post-radiation therapy), recent burns, sepsis, contusions, pitted edemas, 24 to 48-hours after any type of anti-inflammatory treatment, varicose veins, phlebitis, and Frostbite and may spread or worsen such conditions. The massage therapist will perform a body scan of massage areas. Unaffected body areas can receive massage, affected areas will not. I UNDERSTAND that it is recommended that skin conditions be seen by a licensed esthetitican, dermatologist or GP Signature:___________________________________Date:___________

Please mark your conditions, areas of concern.


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