1. health and fitness
2. therapy

Health History for Enlighten Therapeutic Massage Date of Initial Visit: Name: Address: Phone: Email: Occupation: Date of Birth How did you hear about Enlighten Therapeutic Massage? ___________________________ THE FOLLOWING INFORMAITON WILL BE USED TO HELP PLAN SAFE AND EFFECIVE MASSAGE SESSIONS. PLEASE ANSWER THE QUESTIONS TO THE BEST OF YOUR KNOWLEDGE. 1. Have you had a professional massage before? YES NO 2. Do you have any difficulty lying on your FRONT, BACK or SIDE? YES NO a. If yes, please explain:____________________________________________________ 3. Are you sensitive to touch or pressure in any area? a. If yes, please explain: ___________________________________________________ 4. Do you have allergic reactions to oils, lotions, ointments, liniments, or other substances put on your skin? YES NO a. If yes, please explain: ___________________________________________________ 5. Do you wear contact lenses Y/N; Dentures Y/N; Hearing Aid Y/N? 6. Do you sit for long hours at a workstation, computer, or driving? YES NO a. If yes, please explain: ____________________________________________________ 7. Do you perform any repetitive movement in you work, sports or hobby? YES NO a. If yes, please explain: ___________________________________________________ 8. Are you under a care of a physician? a. If yes, please explain: __________________________________________________ 9. Are you pregnant? a. If yes, how far along? __________________________________________________ 10. Are you currently taking any medications? a. If yes, please list _______________________________________________________ List of medications List surgeries /cosmetic surgeries/ injuries Goals for Today: What do you prefer during a massage?  Release Tension/ Tightness  Light pressure  Improve Athletic Performance  Medium pressure  Muscle Education /Re-­‐Education  Deep pressure  Relaxation/ Reduced Stress  Relief from Pain/ Stiffness  Maintenance Massage 1 Are there any parts of your body that you would like more time spent on during the massage? Please circle: Are there any parts of your body that would like to be avoided during the massage? Face Legs Upper Arms Scalp Feet Forearms Neck Hands Gluteal/s Shoulders Stomach Face Legs Upper Arms Scalp Feet Forearms Neck Hands Gluteal/s Shoulders Stomach Please circle: Upper Back Mid Back Lower Back Other:_________ Upper Back Mid Back Lower Back Other:_________ Mark areas of Discomfort: Please mark an (X) by all current conditions and (P) for all past conditions
__ Abdominal /digestive
problems
__ Allergies
__ Anxiety
__ Arthritis/tendonitis
__ Asthma or lung cond.
__ Athletes foot
__ Blood clots
__ Chronic pain
__ Circulatory/heart
problems
__ Constipation/diarrhea4
].,
__ Depression
__ Diabetes
__ Fatigue
__ Headaches, migraine
__ Hearing problems
__ Hernia
__ High blood pressure
__ Jaw pain/TMJ pain
__ Low blood pressure
__ Muscle/bone injuries
__ Muscle/joint pain
Elaborate on noted areas above:
2 __ Numbness/tingling
__ Pregnancy
__ Rash/fungus
__ Sinus problems
__ Sleep difficulties
__ Spinal disorders
__ Sprain/strain
__ Tension/stress
__ Vision problems
__Varicose veins
__ Other
________________
The therapist can massage but not over any areas affected by the following:  Varicose veins  Undiagnosed lumps or bumps  Pregnancy  Bruising  Cuts  Abrasions  Sunburn  Undiagnosed pain  Inflammation, including arthritis Medical Contraindications: Total Contraindications When you have any of these conditions, please do not book a massage:  Fever  Contagious diseases, including any cold or flu, no matter how mild it may seem  Under the influence of drugs or alcohol-­‐including prescription pain medication  Recent operations or acute injuries  Neuritis  Skin diseases M edical Contraindications : If you suffer from any of the follow ing conditions, m assage can only take place once you have approval in writing by your Physician.  Cardio-­‐vascular conditions (thrombosis, phlebitis, hypertension, heart conditions)  Any condition already being treated by a medical practitioner  Oedema  Psoriasis or eczema  High blood pressure  Osteoporosis  Cancer  Nervous or psychotic conditions  Heart problems, angina, those with pacemakers  Epilepsy  Diabetes  Bell’s palsy, trapped or pinched nerves  Gynecological infections Does a contraindication mean that treatment cannot take place? Not always. In fact, massage can be very therapeutic for many medical conditions. However, in the above cases it is best to have advice 3 from your physician. Massage therapists, unless they are also qualified doctors, may not, under law, attempt to diagnose a condition. I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated. I understand that I am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever. Client Signature: ___________________________________________ Date: _____________ 4