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Client Health Waiver
First & Last Name
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Biological Gender
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Occupation
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Emergency Contact Name & Phone Number
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Have you recieved energetic bodywork or massage before? (If yes, please state how frequently)
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Do you have difficulty lying on your front, back, or side? (If yes, please explain)
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Do you wear contacts, dentures or a hearing aid?
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Do you sit for long hours at a workstation, computer, or driving?
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Do you perform any repetitive movement in your work, sports, or hobby? (If yes, please describe)
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Do you experience stress in your work, family, or other aspect of your life?
How do you find that stress manifests in terms of your health? I.e as muscle tension, anxiety, irritability, insomnia etc
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Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort - stress related or otherwise?
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Do you see a Chiropractor/Osteopath?
Do you have a Medical Doctor?
Are you currently taking any medications? I.e contraception, blood thinners, anti-depressants etc
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Please check any conditions listed below that apply to you:
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Please check any conditions listed below that apply to you:
Recent accident/injury/fracture/surgery
Decreased sensation
Open sores or wounds
Arthritis
Sprains/strains
Fibromyalgia
Allergies/sensitivities
Osteoporosis
Easy bruising
Artificial Limbs or Joints
Skin condition (Acne， Rosacea， Eczema， Psorisis， Fungal， Contagious and others)
Joint Hypermobility Syndrome
Swollen glands
Cancer or in recovery
High or low blood pressure
Severe anxiety/panic attacks
Atherosclerosis
PTSD
Heart condition
Adjustment Disorders
Circulatory disorder
Dissociative Disorders
Deep vein thrombosis
ADD/ADHD
Varicose veins
None of the above
Diabetes
(Female Only) - Will you be having/due your menstruation or are you in any menopausal stage at the time of your appointment?
Is there anything else about your health history that you think would be useful to know in order to plan a safe and effective massage treatment for you?
Please confirm you have read the Terms & Conditions and sign your health waiver form
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Signature
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Submit
