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One ♥ Medium
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Coaching
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Mediumship
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Living Inspiration
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Mama Guru
One ♥ Medium
Whole Body Healing Session
First Session Intake Form
Name
*
First Name
Last Name
Email
*
Phone (day)
*
(###)
###
####
Phone (eve)
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of birth
Occupation
Emergency Contact Name and Phone Number
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
Have you had a professional massage before?
Yes
No
If yes, how often do you receive massage therapy?
Do you have any difficulty lying on your from, back, or side?
Yes
No
If yes, please explain:
MEDICAL HISTORY In order to plan a massage session that is safe and effective, I need some general information about your medical history.
Are you currently under medical supervision?
Yes
No
If yes, please explain:
Do you see a chiropractor?
Yes
No
If yes, how often?
Please check any condition that applies to you:
contagious skin condition
open sores or wounds
easy bruising
recent accident or injury
recent fracture
recent surgery
artificial joint
sprains/strains
current fever
swollen glands
allergies/sensitivity
heart condition
high or low blood pressure
circulatory disorder
varicose veins
artherosclerosis
phlebitis
deep vein thrombosis/blood clots
joint disorder/rheumatoid arthritis/osteoarthritis/tendonitis
osteoporosis
epilepsy
headaches/migraines
cancer
diabetes
decreased sensation
back/neck problems
fibromyalgia
TMJ
carpal tunnel syndrome
tennis elbow
pregnancy
Please explain any condition that you have marked above:
Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Draping will be used during the session - only the area being worked on will be uncovered. 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 of legal guardian for any client under the age of 17. I understand that the massage I receive is proved for the basic purpose of relaxation and relief of muscular tension. 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 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 mown 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 therapist's part should I fail to do so.
Please initial to accept and agree the above.
Thank you!
