Online Massage Form

Davis Chiropractic - Massage Therapy

13479 West Center Rd.

Omaha, NE 68144

(402) 964-2930

Client Information

Name____________________ Phone (____)-_____________ DOB ______________

Address __________________________ City___________ State____  Zip________

E-mail ______________________________________________________________

Referred by ______________________  Phone (____)-_________________

In case of emergency: _______________________  Phone (____)-_____________

Occupation _________________  (circle one)  Male or Female  Physician_______________

Health Insurance Carrier ___________________________________________________

_________________________________________________________________________

Please take a moment to carefully read the following information and sign where indicated.  If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated.  A referral from your care provider may be required prior to service being provided.

Have you ever experienced a professional massage or bodywork session? YES    NO 

If yes, how recently? ________________

What are your massage or bodywork goals?_____________________________________

What kind of pressure do you prefer? (circle one)  light   medium   firm

IF YOU ANSWER "YES" TO ANY OF THE FOLLOWING QUESTIONS, PLEASE EXPLAIN AS CLEARLY AS POSSIBLE

Please mark all that apply to you

Do you frequently suffer from stress? ___      Do you bruise easily? ____

Do you have diabetes?___                            Any broken bones in the past 2 years?___

Do you experience frequent headaches? __   Any injuries in the past 2 years? ___

Are you pregnant? __                                   Are you wearing dentures? ___

Do you suffer from arthritis? ___                 Do you have high blood pressure medications? __

Are you wearing contact lenses? ___           Do you suffer from epilepsy or seizures? ___

Do you suffer from joint swelling? ___         Do you have varicose veins?___

Do you have osteoporosis? ___                   Do you have allergies?___

Do you have tension or soreness in a specific area?___ Please specify_____________

_________________________________________________________________

Do you have cardiac or circulatory problems? ___

Do you suffer from back pain? ___               Do you have numbness or stabbing pains?___

Have you ever had surgery?______________________________________________

Are you sensitive to touch or pressure? ___

Other medical conditions or are you taking medications I should know about? ______

Comments: __________________________________________________________

___________________________________________________________________

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session I will immediately inform the practitioner so that the pressure and strokes may be adjusted to my level of comfort.  I further understand that massage 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 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 should be construed as such because massage should not be performed under certain medical conditions, I affirm that I have stated all of 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 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.

Client signature _________________________________  Date __________________

Practitioner signature ____________________________   Date __________________

Consent to Treatment of Minor: By my signature below, I hereby authorize ___________________ to administer massage/bodywork and somatic therapy techniques to my child or dependent as they deem necessary.

Parent/Guardian Signature ________________________________________________