Laura's Integrated Functional Therapy

Giving a Lift to Your Mind, Body, & Spirit

Client Forms


 

                      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

Associated Bodywork & Massage Professionals
© Copyright 2017 Laura's Integrated Functional Therapy. All rights reserved.