Your name
Date of Birth
Address
Your email
Your phone Number
Occupation
Referred by
Name Number
Have you ever had a professional massage or bodywork session? YesNo
Do you frequently suffer from stress? YesNo
Do you experience frequent headaches? YesNo
Are you pregnant? YesNo
Are you wearing contact lenses? YesNo
Are you a diabetic? YesNo
Do you have high blood pressure? YesNo
Are you epileptic? YesNo
If you have any of the above, are you taking medication for it? YesNo
If answered YES to any of the above questions, please explain briefly
How often do you exercise? Seldom1 x per week2 x per week3 x per week+ Active Sport
Have you ever had surgery? YesNo
Have you had any broken bones in the last two years? YesNo
Do you have any tension or soreness in specific area? YesNo
Do you have any cardiac or circulation problems? YesNo
Do you suffer from any back pain? YesNo
Do you have any numbness or stabbing pain anywhere? YesNo
Do you have any other medical conditions that I should be aware of? YesNo
Are you sensitive to touch/pressure in any area? YesNo
Any questions answered YES to, will be discussed prior to your session beginning
By sharing your patient information you agree and understand that the massage/sports massage and therapeutic bodywork are provided for the basic purpose of relaxation, stress reduction and relief of muscular tension, increased blood flow, increase in general muscle and tendon mobility and improving general wellbeing. If you experience any pain or discomfort during this session, you will immediately inform the practitioner so that the pressure, strokes, and or exercise may be adjusted to your level of comfort.
You further understand that massage/bodywork therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that you should see a physician or other qualified medical specialist for any physical ailment that you are aware of.
You understand that massage therapists/sport 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(s) given should be construed as such.
Because massage/bodywork therapy is contraindicated (should not be done) under certain medical conditions, you affirm that you have stated all your medical conditions, and answered all the questions honestly. You agree to keep the practitioner updated as to any changes in your medical profile and understand that there shall be no liability on the practitioner’s part should you forget to do so. You hereby absolve By Grace Massage & Katherine Montano from any liability (or perceived liability) whatsoever, arising from any medical conditions, existing or undiagnosed, that were stated or omitted in this form.
It is also understood that illicit or sexually suggestive remarks or advances made by you will result in the immediate termination of the session and you will be liable for the payment of the full scheduled appointment.
By providing the above information you agree that you've read and understand the Patient Information Policy and you agree to the information stated in the policy.
I agree that I've read and understand the above information
