Massage Health Form

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 *

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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? *

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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	Muscle or joint pain Current	Muscle or joint pain Past	Muscle or joint pain None
Muscle or joint stiffness	Muscle or joint stiffness Current	Muscle or joint stiffness Past	Muscle or joint stiffness None
Numbness or tingling	Numbness or tingling Current	Numbness or tingling Past	Numbness or tingling None
Swelling	Swelling Current	Swelling Past	Swelling None
Bruise easily	Bruise easily Current	Bruise easily Past	Bruise easily None
Sensitive to touch/pressure	Sensitive to touch/pressure Current	Sensitive to touch/pressure Past	Sensitive to touch/pressure None
High/Low blood pressure	High/Low blood pressure Current	High/Low blood pressure Past	High/Low blood pressure None
Stroke, heart attack	Stroke, heart attack Current	Stroke, heart attack Past	Stroke, heart attack None
Varicose veins	Varicose veins Current	Varicose veins Past	Varicose veins None
Shortness of breath, asthma	Shortness of breath, asthma Current	Shortness of breath, asthma Past	Shortness of breath, asthma None
Cancer	Cancer Current	Cancer Past	Cancer None
Neurological (e.g. MS, Parkinson’s, chronic pain)	Neurological (e.g. MS, Parkinson’s, chronic pain) Current	Neurological (e.g. MS, Parkinson’s, chronic pain) Past	Neurological (e.g. MS, Parkinson’s, chronic pain) None
Epilepsy, seizures	Epilepsy, seizures Current	Epilepsy, seizures Past	Epilepsy, seizures None
Headaches, Migraines	Headaches, Migraines Current	Headaches, Migraines Past	Headaches, Migraines None
Dizziness, ringing in the ears	Dizziness, ringing in the ears Current	Dizziness, ringing in the ears Past	Dizziness, ringing in the ears None
Digestive conditions (e.g. Crohn’s, IBS)	Digestive conditions (e.g. Crohn’s, IBS) Current	Digestive conditions (e.g. Crohn’s, IBS) Past	Digestive conditions (e.g. Crohn’s, IBS) None
Gas, bloating, constipation	Gas, bloating, constipation Current	Gas, bloating, constipation Past	Gas, bloating, constipation None
Kidney disease, infection	Kidney disease, infection Current	Kidney disease, infection Past	Kidney disease, infection None
Arthritis (rheumatoid, osteoarthritis)	Arthritis (rheumatoid, osteoarthritis) Current	Arthritis (rheumatoid, osteoarthritis) Past	Arthritis (rheumatoid, osteoarthritis) None
Osteoporosis, degenerative spine/disk	Osteoporosis, degenerative spine/disk Current	Osteoporosis, degenerative spine/disk Past	Osteoporosis, degenerative spine/disk None
Scoliosis	Scoliosis Current	Scoliosis Past	Scoliosis None
Broken bones	Broken bones Current	Broken bones Past	Broken bones None
Allergies	Allergies Current	Allergies Past	Allergies None
Diabetes	Diabetes Current	Diabetes Past	Diabetes None
Endocrine/thyroid conditions	Endocrine/thyroid conditions Current	Endocrine/thyroid conditions Past	Endocrine/thyroid conditions None
Depression, anxiety	Depression, anxiety Current	Depression, anxiety Past	Depression, anxiety None
Memory Loss, confusion, easily overwhelmed	Memory Loss, confusion, easily overwhelmed Current	Memory Loss, confusion, easily overwhelmed Past	Memory 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.

Client Signature *

Sign Date

Parent or Guardian Signature (in case of a minor)

Sign Date

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Client Contact Information

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Consent for Treatment

To book an appointment call or text (818) 430-7373 or email info@angelcityhealing.com