Body Balance Chiropractic & Wellness Center

Personal Information

First Name

Last Name

Sex

Birth Date

MM

DD

YYYY

Height

Weight

Address

City

State

Zip

Home Phone

Email Address

Occupation

Employer

Mailing List

How did you hear about these services?

Have you had a massage before? If yes, how many?

Do you have any past experience that would make you feel uncomfortable or have difficulty with massage?

If yes, please explain or privately confer with the therapist.

Are there any aspects of your life that are particularly stressful?

Job
Habits
Diet
Family/Children
posture
Other/Explain?

Are there any areas where you seem to hold a lot of tension or any areas you would like to have extra time spent?

Medical Information

Are you under a Physicians care? if, yes, please explain

Are you taking any medications or supplements? if, yes, please list

Do you wear contacts?

Yes
No

Do you have, or have you had within the last two years, any of the following conditions?

Please explain & date any yes answers below

Do we have permission to contact your doctor, chiropractor ot other practitioner?

Yes
No

Physician

Phone

Are you Pregnant?

Yes
No

Do you think you may be?

Yes
No

Activities/Sports/Exercise

How often?

Have you traveled anywhere in the last 6 months? If so where?

Yes
No

Organized Sports?

Yes
No

Which ?

Do you have any upcoming events?

Yes
No

When ?

Exercise - Weights, Walking, biking, etc. ?

How often?

I understand the massage services which I receive are designed to be a Health Aid and are in no way to take the place of a Doctor's Care when such care is indicated. I understand that massage therapists do not perform spinal or skeletal adjustments, diagnose illness, disease or any physical or mental disorders, prescribe pharmaceuticals and that nothing said during the session(s) should be constructed as such. If I have a specific medical condition or specific symptoms for which massage may be contraindicated, a referral from my primary care provider may be required before services are provided. I take full and unqualified responsibility to keep the therapist updated as to any changes in my medical profile, and understand and agree that there shall be no liability on the therapist part should I fail to do so. If i experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort, Inappropriate actions or language in cause for termination of a treatment and the client will be responsible for payment of the appointment in full. We reserve the right to refuse service to anyone.

State Law requires the following acknowledgments:
The Massage Therapist is required to have an initial consultation and discuss the type of massage anticipated using, the parts of the body to be massaged or avoided, including indications and contraindications (should not be done).

Therapist Signature

Client

I understand that the therapist may massage three inches just below of the clavicle in order to relieve tension in the neck. If you consent please initial bellow."

Client's Initial

I understand if I am uncomfortable for any reason I may terminate/cease the massage session and the therapist is required to end the session. Because massage is contraindicated (should not be massaged) under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. If this is for a Minor; then as parent or guardian I hereby give permission for massage services for the person listed on this form.

Client's Initial

Patient or Guardian Signature

Step 1 of 4

Personal Information

Medical Information

Activities/Sports/Exercise