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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
Please check any conditions listed below that apply to you:
Decreased sensation
Please check any conditions listed below that apply to you:
Open sores or wounds
Please check any conditions listed below that apply to you:
Arthritis
Please check any conditions listed below that apply to you:
Sprains/strains
Please check any conditions listed below that apply to you:
Fibromyalgia
Please check any conditions listed below that apply to you:
Allergies/sensitivities
Please check any conditions listed below that apply to you:
Osteoporosis
Please check any conditions listed below that apply to you:
Easy bruising
Please check any conditions listed below that apply to you:
Artificial Limbs or Joints
Please check any conditions listed below that apply to you:
Skin condition (Acne， Rosacea， Eczema， Psorisis， Fungal， Contagious and others)
Please check any conditions listed below that apply to you:
Joint Hypermobility Syndrome
Please check any conditions listed below that apply to you:
Swollen glands
Please check any conditions listed below that apply to you:
Cancer or in recovery
Please check any conditions listed below that apply to you:
High or low blood pressure
Please check any conditions listed below that apply to you:
Severe anxiety/panic attacks
Please check any conditions listed below that apply to you:
Atherosclerosis
Please check any conditions listed below that apply to you:
PTSD
Please check any conditions listed below that apply to you:
Heart condition
Please check any conditions listed below that apply to you:
Adjustment Disorders
Please check any conditions listed below that apply to you:
Circulatory disorder
Please check any conditions listed below that apply to you:
Dissociative Disorders
Please check any conditions listed below that apply to you:
Deep vein thrombosis
Please check any conditions listed below that apply to you:
ADD/ADHD
Please check any conditions listed below that apply to you:
Varicose veins
Please check any conditions listed below that apply to you:
None of the above
Please check any conditions listed below that apply to you:
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
