high blood pressure emphysema shortness of breath · high blood pressure emphysema shortness of...
Post on 16-Jul-2020
4 Views
Preview:
TRANSCRIPT
Name: ___________________________________________________________ Date: __________________
Address: _________________________________________________________________________________
Birthday: ______________________ Occupation: _______________________________________________
Phone Number: _____________________ Email: _______________________________________________
Emergency Contact (name and phone): ______________________________________________________
Would you like to receive emails letting you know of promotions or changes? Y / N
Allergies? __________________ Prescription Medications? ______________________________________
Surgeries/Falls/ Accidents (last 5 years)? _____________________________________________________
_________________________________________________________________________________________
Are you being treated by other Healthcare Professionals? ______________________________________
Medical Implants/Wires? ___________________________________________________________________
Diagnoses/Illnesses/Concerns? _____________________________________________________________
Overall, how do you feel about your health? __________________________________________________
What pressure do you prefer for your massage? Lighter Medium Firm
Please circle any areas of discomfort, and elaborate below if
need: ____________________________________________________
Please check conditions you have had or are currently experiencing, as well as make a note of
anything else relevant to your health that you should disclose before beginning massage therapy.
Women: Are you currently pregnant? When are you due: ______________________________________
Are you experiencing any difficulty during this pregnancy? ______________________________________
Have you had prenatal massages before? ____________________________________________________
I have informed the massage therapist of all my known conditions and medications. I will continue to
update any changes in my health history. I understand that:
• I may ask questions about anything at anytime.
• All client information is confidential and written authorization must be obtained to release any
information to other caregivers
• Any contraindications to massage therapy that are relevant to me
• I understand the assessment and treatment to be preformed and that draping will only expose
areas requiring treatment
• That at anytime I can withdraw my consent and treatment will be stopped without a question
• The duration and cost of the massage therapy treatment
• That massage therapy is not a substitute foe medical treatment or medications
• That it is recommended that I work with my primary caregiver for any condition I may have
• That a massage therapist will not diagnose illness or disease and will not prescribe medication
Signature: ______________________________
Date: __________________________________
High Blood Pressure Emphysema Shortness of Breath
Varicose Veins/Phlebitis Chronic Congestive Heart Troubled Skin
Low Blood Pressure Pacemaker Asthma
Stroke / CVA Heart Disease Headaches / Migraine
Chronic Cough Bronchitis Mental Illness
Arthritis Loss of sensation Epilepsy
Diabetes Ear troubles / loss HIV/Aids
top related