~~~~~~~~~~~~~~ HEALTH SCREEN ~~~~~~~~~~~~~~

PATIENT INFORMATION DATE ___________________

NAME ________________________________ DATE OF BIRTH ___________

ADDRESS ____________________________ PHONE (H) ____________________

____________________________ (W) ______________________

____________________________

OCCUPATION _________________________

ARE YOU PRESENTLY UNDER A DOCTOR’S OR THERAPIST’S CARE? __________

IF SO, FOR WHAT? ________________________________________________________

HAVE YOU EVER HAD A PROFESSIONAL MASSAGE OR OTHER TYPE OF BODYWORK? _____
IF SO, WHAT KIND(S)____________________________________________________

WHAT DO YOU HOPE TO GAIN FROM THE BODY WORK? _________________________

MEDICAL CONDITIONS Please list or circle any medical conditions. Include any recent rashes, bruises, bumps, breaks, sprains, strains, fractures or illnesses. A partial list follows but is not meant to be all inclusive.

Abscess/open sore/surgical site		Fibromyalgia		Implants?
Allergies		Fibrositis			where?_____________
Arteriosclerosis		Headaches		PMS/troublesome cycle
Asthma		Heart disease		Osteoarthritis
Cancer/malignancy		Herniated disc		Osteoporosis
	type:_____________________	Hepatitis		Rheumatoid arthritis
	diagnosed date:____________	Herpes I or II		Skin sensitivity
	last treatment:______________	History of: mental illness,		Stomach ulcers
Chronic fatigue syndrome		physical or emotional abuse,		Varicose veins
Chronic pain (where?)		counseling/therapy		Poor circulation
Depression		Carpal Tunnel Syndrome		Phlebitis
Diabetes		HIV/AIDS		Pregnant
Digestive problems			diagnosed date: _______	Recent Surgery
Easy bruising			last treatment:_________	Blood Clots
Epilepsy		Hypertension		Taking medication
Fluid retention		Inner ear problems		Insomnia
Fractures/breaks/bone injury		Infection		Cold or flu
Disc (ruptured or bulged?)		Bunion		Neuroma
Unsuccessful surgery		Charcot Foot		Peripheral Neuropathy
Joint injury		Hammer toe		Cerebral Palsey
Knee injury		Hip injury		Parkinsons
Thoracic Outlet Syndrome		Whiplash		Stroke
Frozen shoulder		Rotator Cuff Injury		Spinal Cord Injury
Other conditions (including past injuries that still affect you):

Name of Health Care Provider: ______________________________ Phone: ___________________

City: _____________________________ State: ________________________ Zip code: _________

Do I have permission to contact your Health Care Provider, should the need arise? Yes ____ No ___

LIFE STYLE

(Please circle)

Do you exercise? Yes No How often? ________________ What type?___________

Do you use: Tobacco? Yes No Alcohol? Yes No Caffeine? Yes No

Any nutritional/eating concerns? _________________________________________________

On a scale of 0 to 10 (highest), what is your stress level today? ______________

… what is your pain level today? ______________

Is there any area of the body where you seem to hold a lot of tension? ____________________

I understand that massage practitioners are not trained in the diagnosis and treatment of diseases. I confirm that I have consulted a medical doctor for all the conditions checked and have received authorization to have a massage. By signing this release, I do hereby waive and release the massage practitioner from all liability, past, present and future.

SIGNATURE ________________________________________DATE ________________

*If you have any concerns, please feel free to inquire about them.