Laura’s Integrated Functional Therapy
Health Information
Client Contact Information
Client Name: ___________________________________ Date: _____________________
Date of Birth: ____________ Gender: ____________
Address_____________________________City:____________________State:________
Phone: _____________________ Email: _______________________________________
Referred by: ___________________________________
Emergency contact: _______________________Phone:___________________________
Occupation:_____________________________________
Massage Information
Have you ever received professional massage/bodywork before? Yes ☐No ☐
What kind of pressure do you prefer? Light Medium Firm
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have you had any injuries or surgeries in the past that may influence today’s treatment?
_____________________________________________________________________________________________
Circle 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 Muscle or joint pain _____________________________________
Current Past Numbness or tingling ____________________________________
Current Past High/Low blood pressure _____________________________________
Current Past Stroke, heart attack _____________________________________
Current Past Shortness of breath, asthma _____________________________________
Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________
Current Past Epilepsy, seizures _____________________________________
Current Past Headaches, Migraines _____________________________________
Current Past Dizziness, ringing in the ears _____________________________________
Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________
Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________
Current Past Osteoporosis, degenerative spine/disk _____________________________________
Current Past Broken bones _____________________________________
Current Past Allergies _____________________________________
Current Past Endocrine/thyroid conditions _____________________________________
Current Past Depression, anxiety _____________________________________
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: _____________________________________________________________ Date: ____________
Screening Questionnaire form
Body Map for Clients
Client Feedback form
Physician's Permission form
Physician's Referral form
