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Consent form

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

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Muscle or joint pain _____________________________________

Muscle or joint stiffness _____________________________________

Numbness or tingling _____________________________________

Swelling _____________________________________

Bruise easily _____________________________________
Sensitive to touch/pressure _____________________________________
High/Low blood pressure _____________________________________
Stroke, heart attack _____________________________________
Varicose veins _____________________________________
Shortness of breath, asthma _____________________________________
Cancer _____________________________________
Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________

Epilepsy, seizures _____________________________________
Headaches, Migraines _____________________________________
Dizziness, ringing in the ears _____________________________________
Digestive conditions (e.g. Crohn’s, IBS) _____________________________________
Gas, bloating, constipation _____________________________________
Kidney disease, infection _____________________________________
Arthritis (rheumatoid, osteoarthritis) _____________________________________

Osteoporosis, degenerative spine/disk _____________________________________
Scoliosis _____________________________________
Broken bones _____________________________________
Allergies _____________________________________
Diabetes _____________________________________
Endocrine/thyroid conditions _____________________________________
Depression, anxiety _____________________________________
Memory Loss, confusion, easily overwhelmed _____________________________________

 

 

Comments:

 

 

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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 another 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: ____________ 

 

 

Parent or Guardian Signature (in case of a minor): ___________________________________ 

 

 

Date: ____________

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