Embody Massage

 

Jessi Westhoven, Licensed Massage Therapist, Physical Therapy Assistant 

 

CPR certified and insured (by NACAMS)

Licensed by the Ohio State Medical Board and the Physical Therapy section of the OTPTAT Board of Ohio

 

Health Questionaire

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Name: ___________________________________  Occupation: _________________________

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Address: __________________________ City: _____________ State: _____ Zip: ___________

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Daytime Phone: (_____) _________________  Evening Phone: (_____) __________________

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Email Address: ______________________________________________ DOB: _____________

 

Emergency Contact: ____________________________ Phone: (_____) __________________

 

 

 

Massage Experience

 

How did you hear about us? _____________________________________________________

 

Have you ever had a professional massage before?  Y /  N

 

If yes, when was your last massage? _______________________________________________

 

What type of massage? (ex. Swedish, Deep Tissue, etc) _______________________________

 

What is your goal for today? _____________________________________________________

 

What type of pressure do you like? (Please Circle)  Light—-Medium—-Firm—-Deep

 

Are you uncomfortable with any of the following areas to be massaged:

 

Gluteal Region  (Y/N)          Pectoral Region  (Y/N)             Face/Scalp  (Y/N)             Feet  (Y/N)

 

 

 

Health History

 

Please list any medications or supplements you are currently taking and explain: _________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

 

Please list any injuries/accidents/illnesses still affecting you: _______________________________________

 

_________________________________________________________________________________________

 

 

 

Please list any surgeries and explain: __________________________________________________________

 

_________________________________________________________________________________________

 

 

 

Please identify the areas of concern or goals for the session: _________________________________________________________________________________________

 

_________________________________________________________________________________________

 

 

Health History

 

Please indicate any Present (P), Past (X), or Reoccurring (C) conditions:

 

 

 

____ ADD/ADHD                                                                      ____ Mononucleosis

 

____ Allergies                                                                          ____ Multiple Sclerosis

 

____ Alzheimer’s disease                                                        ____ Muscular Dystrophy

 

____ Anxiety disorder                                                              ____ Numbness/ Tingling

 

____ Arthritis                                                                           ____ Osteoporosis/Osteopenia

 

____Osteoarthritis                                                                   ____ Pain

 

____ Rheumatoid Arthritis                                                       –Location: ____________________

 

____ Athletes foot                                                                    –Muscular or Joint: _____________

 

____ Asthma                                                                            — Chronic?  Y/N

 

____ Blood Clot/ Deep Vein Thrombosis/                               ____ Paralysis

 

Phlebitis/ Embolism                                                                 ____ Parkinson’s disease

 

____ Broken or fractured bones                                              ____ Pregnancy

 

____ Bursitis                                                                            ____ Psoriasis

 

____ Cancer                                                                             ____ Rash

 

–Location: ___________________                                         ____ Sciatica

 

–Treatment: __________________                                        ____ Scoliosis

 

– In Remission?  Y/N                                                               ____ Seizure

 

____ Carpal Tunnel Syndrome                                                ____ Sleeping problems

 

____ Cerebral Palsy                                                                ____ Spasms/ Cramping

 

____ Chronic Fatigue Syndrome                                             ____ Strain/ Sprain

 

____ Contagious condition                                                     ____ Stroke

 

____ Crohn’s disease                                                              ____ Tendonitis

 

____ Depression                                                                      ____ Thyroid issues

 

____ Diabetes                                                                          ____ TMJ/ Jaw Pain

 

____ Type I                                                                               ____ Tumor

 

____ Type II                                                                             –Location: ____________________

 

____ Diverticulitis                                                                   –Malignant or Benign? ___________

 

____ Eczema                                                                            ____ Varicose Veins

 

____ Epilepsy                                                                           ____ Visually impaired

 

____ Epstein Barr                                                                     ____ Other: _________________________

 

____ Fertility Concerns                                                                                  

 

____ Fibromyalgia                                                                                      

 

____ General Fatigue                                                                                 

 

____ Gout                                                                                                     

 

____ Headaches

 

–Type: _____________________

 

–Frequency: ________________

 

____ Hearing Impairment

 

____ Heart Condition

 

____ Herpes/ Shingles

 

____ High/ Low Blood Pressure

 

____ High/ Low Cholesterol

 

____ HIV/AIDS

 

____ Infection

 

____ Lupus

 

____ Lymphedema

 

 

 

Informed Consent

 

By signing this, I agree that I have answered all questions to the best of my knowledge and that I will inform the therapist of any changes in my condition or medication. If I experience any pain/discomfort or would like the pressure adjusted, I will inform the therapist immediately.

 

 

I understand that a massage therapist cannot diagnosis any illness, disease, or any physical or mental disorders nor can the therapist prescribe any medication and that nothing said in a session should be construed as such. I understand that massage therapy is intended to work in conjunction with my health care, not act as a substitute for medical examination.  I understand that it is my responsibility to consult a physician for any ailments I may have.

 

 

I understand that massage therapy is a therapeutic measure used to reduce stress, muscular tension, and pain. I understand there are no guarantees for recovery and if I am unsatisfied with the progress made with my treatment I will inform the therapist, so he/she may direct me to another treatment. I also understand that massage therapy is non-sexual in nature and any advancement made will terminate the massage.

 

 

I agree to abide by a 24 hour cancellation notice for any scheduled massage. I understand I may be charged up to the full amount of service for missed appointments or for any cancellations with less than a 24 hour notice. I understand that walk-ins are welcome, but does not guarantee the availability for a massage. I understand that if I arrive late for an appointment, the session will end at the original scheduled time to prevent penalizing another client. However, if the massage therapist is late, he/she will fulfill the scheduled massage length or offer a reasonable compensation.

 

 

I understand that if I use a coupon during my visit, it is not valid with any other coupons or promotions.

 

 

I agree that I am of legal age (18 years old) and that if I am not, I agree to have my parent or guardian sign a parental/guardian release form before treatment.

 

 

I understand that certain conditions or medications may contraindicate (not permit) massage or may require the use of alternate techniques or pressure. I respect the decision of the massage therapist and am fully prepared to reschedule the massage for a later date if requested by the massage therapist. I also understand that massage may be advisable by my physician, but not by a massage therapist. In that event, I agree to provide a written agreement from my physician before proceeding with treatment.

 

 

 

 

 

Print Name: __________________________________________________________________

 

 

 

 

 

Signature: ____________________________________________________________________

 

 

 

 

 

Date: ________________________________________________________________________