Massage Health Form - Angel City Healing

Client Contact Information

Have you visited us before? *

Yes, I’m a returning client
No, I’m a new client

Has anything changed in your health since your last visit? *

Client Name *

First

Last

Date of Birth *

Gender *

Male
Female

Are you pregnant? *

Are you in your first trimester? *

A massage is medically contraindicated in the first trimester of pregnancy. Please contact Angel City Healing for more details.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone

Referred by

Physician/Healthcare Provider's Name

Physician/Healthcare Provider's Phone

Emergency Contact: *

Emergency Contact Phone *

You’re all set here. Move to the step next step

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? *

Do you have a physician referral/prescription? *

Please provide details *

Have you ever received professional massage/bodywork before? *

How recently?

What types of massage/bodywork do you prefer?

What kind of pressure do you prefer?

Light
Medium
Firm

What are your goals/expected outcomes for receiving massage/bodywork?

Are you currently experiencing any pain? *

Tell us your pain level

Selected Value: 1

Where are you experiencing pain? Please provide a detailed description of the location

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.)

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?

Please explain

Do you have any allergies? *

Please list your allergies

List the medications you currently take *

Are you wearing contacts? *

Are you wearing dentures? *

Are you wearing a hairpiece? *

You’re all set here. Move to the step next step

Have you had any injuries or surgeries in the past that may influence today’s treatment? *

Please explain

Check any of the following health conditions that you currently have (If you are unsure, please ask)

Blood Clots
Infections
Congestive Heart Failure
Contagious Diseases
Pitted Edema

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received: *

	Current	Past	None
Muscle or joint pain	CurrentMuscle or joint pain Current	PastMuscle or joint pain Past	NoneMuscle or joint pain None
Muscle or joint stiffness	CurrentMuscle or joint stiffness Current	PastMuscle or joint stiffness Past	NoneMuscle or joint stiffness None
Numbness or tingling	CurrentNumbness or tingling Current	PastNumbness or tingling Past	NoneNumbness or tingling None
Swelling	CurrentSwelling Current	PastSwelling Past	NoneSwelling None
Bruise easily	CurrentBruise easily Current	PastBruise easily Past	NoneBruise easily None
Sensitive to touch/pressure	CurrentSensitive to touch/pressure Current	PastSensitive to touch/pressure Past	NoneSensitive to touch/pressure None
High/Low blood pressure	CurrentHigh/Low blood pressure Current	PastHigh/Low blood pressure Past	NoneHigh/Low blood pressure None
Stroke, heart attack	CurrentStroke, heart attack Current	PastStroke, heart attack Past	NoneStroke, heart attack None
Varicose veins	CurrentVaricose veins Current	PastVaricose veins Past	NoneVaricose veins None
Shortness of breath, asthma	CurrentShortness of breath, asthma Current	PastShortness of breath, asthma Past	NoneShortness of breath, asthma None
Cancer	CurrentCancer Current	PastCancer Past	NoneCancer None
Neurological (e.g. MS, Parkinson’s, chronic pain)	CurrentNeurological (e.g. MS, Parkinson’s, chronic pain) Current	PastNeurological (e.g. MS, Parkinson’s, chronic pain) Past	NoneNeurological (e.g. MS, Parkinson’s, chronic pain) None
Epilepsy, seizures	CurrentEpilepsy, seizures Current	PastEpilepsy, seizures Past	NoneEpilepsy, seizures None
Headaches, Migraines	CurrentHeadaches, Migraines Current	PastHeadaches, Migraines Past	NoneHeadaches, Migraines None
Dizziness, ringing in the ears	CurrentDizziness, ringing in the ears Current	PastDizziness, ringing in the ears Past	NoneDizziness, ringing in the ears None
Digestive conditions (e.g. Crohn’s, IBS)	CurrentDigestive conditions (e.g. Crohn’s, IBS) Current	PastDigestive conditions (e.g. Crohn’s, IBS) Past	NoneDigestive conditions (e.g. Crohn’s, IBS) None
Gas, bloating, constipation	CurrentGas, bloating, constipation Current	PastGas, bloating, constipation Past	NoneGas, bloating, constipation None
Kidney disease, infection	CurrentKidney disease, infection Current	PastKidney disease, infection Past	NoneKidney disease, infection None
Arthritis (rheumatoid, osteoarthritis)	CurrentArthritis (rheumatoid, osteoarthritis) Current	PastArthritis (rheumatoid, osteoarthritis) Past	NoneArthritis (rheumatoid, osteoarthritis) None
Osteoporosis, degenerative spine/disk	CurrentOsteoporosis, degenerative spine/disk Current	PastOsteoporosis, degenerative spine/disk Past	NoneOsteoporosis, degenerative spine/disk None
Scoliosis	CurrentScoliosis Current	PastScoliosis Past	NoneScoliosis None
Broken bones	CurrentBroken bones Current	PastBroken bones Past	NoneBroken bones None
Allergies	CurrentAllergies Current	PastAllergies Past	NoneAllergies None
Diabetes	CurrentDiabetes Current	PastDiabetes Past	NoneDiabetes None
Endocrine/thyroid conditions	CurrentEndocrine/thyroid conditions Current	PastEndocrine/thyroid conditions Past	NoneEndocrine/thyroid conditions None
Depression, anxiety	CurrentDepression, anxiety Current	PastDepression, anxiety Past	NoneDepression, anxiety None
Memory Loss, confusion, easily overwhelmed	CurrentMemory Loss, confusion, easily overwhelmed Current	PastMemory Loss, confusion, easily overwhelmed Past	NoneMemory Loss, confusion, easily overwhelmed None

Explain in detail, including treatment received *

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners 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/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

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