Medical History: Please Check All That Apply:
Please choose: High Blood Pressure, diabetes, asthma, epilepsy/seizures, cuts, bruises, fractures, respiratory disorders, low blood pressure, varicose veins, headaches, spinal disorders, psychological disorders, arthritis location, pregnancy, heart diseases, phlebitis, Fibromyalgia, surguries, Gastrointestinal Problem, Muskuloskeletal Disorders, stroke, cancer, gout, stress, TMJ Disfunction, accidents, skin disorders..Please explain any chosen illness.
Please put your Doctor's name, phone and affix your signature.
I understand that the massage/bodywork I receive is provided for the basic purposes of relaxation and relief of muscular tension. There are certain medical conditions in which receiving a massage may not be appropriate. In those cases a referral from a physician may be required prior to services being provided. Massage/bodywork is not a substitute for medical specialist. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure/strokes may be adjusted. In addition, if I am uncomfortable for any reason. I may ask that the session be stopped immediately.
Draping will always be used during sessions. No breast massage will be done without the written consent of the client and the therapist. Any illicit or sexually suggestive remarks or advances made by me ( the client ) or the therapist will result in an immediate termination of the session.