test – no theme Massage Form CompanyThis field is for validation purposes and should be left unchanged.Name* First Last Gender* Female Male Massage InformationDo you have a preference for the gender of the massage therapist?*No PreferenceMale OnlyFemale OnlyWhen was your last professional massage?*neverLess than 1 month ago1 – 3 months ago3 – 6 months ago6 – 12 months agomore than 1 year agoWhat results do you want from your massage today? (check all that apply) Relaxation Stress Relief Sore Muscles Flexibility other Other desired results*What kind of pressure do you prefer for massage?* light medium firm very firm not sure Are you pregnant?* Yes No What stage of pregnancy are you in?*3rd Trimester (27 – 39 weeks)2nd Trimester (14 – 26 weeks)1st Trimester (1 – 13 weeks)Unfortunately you will not be able to receive a massage today. Massage is not permitted for women during their first trimester of pregnancy. After the first trimester, a pre-natal massage is very beneficial to reduce anxiety, decrease symptoms of depression, relieve muscle aches and joint pains, and improve labor outcomes and newborn health. Medications:What medications are you currently taking? Acetaminophen (Anacin, Tylenol) Non-steroidal anti-inflammatory drugs (NSAIDs) (Advil, Motrin, Nuprin, Ibprofen, Indocin, Relefen, Aleve) Salicylates (Aspirin, Bayer, Empirin, Doan’s Pills) Steroidal Anti-inflamatories (Cortisone, Hydrocortone, Prednisone) ACE Inhibitors (Lotensin, Vasotec, Monopril, Zestril, Accupril) Anti-angina medications (Apo-ISDN, Monoket, Transderm-Nitro) Beta blockers (Inderal, Normodyne, Levatol, Tenormin) Calcium channel blockers (Norvasc, Cardizem, Cardene) Cholesterol lowering drugs (LoCholest, Lipitor, Zocor, Crestor, Tricor) Diuretics (Thalidone, Kaluril, Lasix, Bumex, Lozide) Muscle relaxants (such as Soma, Parafon, Forte, Flexeril, Skelaxin, and Myolin) Insulin (Humulin, Humalog, Lantus, Novolog) Oral glucose management drugs (Diabinase, Glocotrol, Glucophage, Precose) other List all other medications that you are currently taking and describe what you are taking them for…* Previous Surgeries and InjuriesHave you had any surgeries?* Yes No Describe the surgeries you've had. Include year and treatment received.*Have you had any accidents?* Yes No Describe the accidents you've had. Include year and treatment received. Health ConditionsCheck any of the following health conditions that you currently have. (check all that apply)if you are unsure, please ask. Please answer honestly, as massage may not be indicated for any of these conditions. blood clots infections congestive heart failure contagious diseases pitted edema Please check any of the following conditions that you currently have or have had in the past. (check all that apply) 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 Allergieis Diabetes Endocrine/thyroid condition Depression, anxiety Memory Loss, confusion, easily overwhelmed Is muscle or join pain a current or past condition?* Current Past Explain your muscle or join pain condition in detail including treatment received.*Is muscle or joint stiffness a current or past condition?* Current Past Explain your muscle or joint stiffness condition in detail including treatment received.*Is numbness or tingling a current or past condition?* Current Past Explain your numbness or tingling condition in detail including treatment received.*Is swelling a current or past condition?* Current Past Explain your swelling condition in detail including treatment received.*Is bruise easily a current or past condition?* Current Past Explain your bruise easily condition in detail including treatment received.*Is sensitive to touch/pressure a current or past condition?* Current Past Explain your sensitive to touch/pressure condition in detail including treatment received.*Is high/low blood pressure a current or past condition?* Current Past Explain your high/low blood pressure condition in detail including treatment received.*Is stroke a current or past condition?* Current Past Explain your stroke condition in detail including treatment received.*Is heart attack a current or past condition?* Current Past Explain your heart attack condition in detail including treatment received.*Is varicose veins a current or past condition?* Current Past Explain your varicose veins condition in detail including treatment received.*Is shortness of breath, asthma a current or past condition?* Current Past Explain your shortness of breath, asthma condition in detail including treatment received.*Is cancer a current or past condition?* Current Past Explain your cancer condition in detail including treatment received.*Is Neurological (e.g. MS, Parkinson's, chronic pain) a current or past condition?* Current Past Explain your Neurological (e.g. MS, Parkinson's, chronic pain) ondition in detail including treatment received.*Is epilepsy, seizures a current or past condition?* Current Past Explain your epilepsy, seizures condition in detail including treatment received.*Is headaches, migraines a current or past condition?* Current Past Explain your headaches, migraines condition in detail including treatment received.*Is dizziness, ringing in the ears a current or past condition?* Current Past Explain your dizziness, ringing in the ears condition in detail including treatment received.*Is digestive conditions (e.g. Crohn's, IBS) a current or past condition?* Current Past Explain your digestive condition (e.g. Crohn's, IBS) in detail including treatment received.*Is gas, bloating, constipation a current or past condition?* Current Past Explain your gas, bloating, constipation condition in detail including treatment received.*Is kidney disease, infection a current or past condition?* Current Past Explain your kidney disease, infection condition in detail including treatment received.*Is arthritis (rheumatoid, osteoarthriitis) a current or past condition?* Current Past Explain your arthritis (rheumatoid, osteoarthritis) condition in detail including treatment received.*Is osteoporosis, degenerative spine/disk a current or past condition?* Current Past Explain your oseoporosis, degenerative spine/disk condition in detail including treatment received.*Is scoliosis a current or past condition?* Current Past Explain your scoliosis condition in detail including treatment received.*Is broken bones a current or past condition?* Current Past Explain your broken bones condition in detail including treatment received.*Is allergies a current or past condition?* Current Past Explain your allergies condition in detail including treatment received.*Is diabetes a current or past condition?* Current Past Explain your diabetes condition in detail including treatment received.*Is endocrine/thyroid a current or past condition?* Current Past Explain your endocrine/thyroid condition in detail including treatment received.*Is depression, anxiety a current or past condition?* Current Past Explain your depression, anxiety condition in detail including treatment received.*Is memory loss, confusion, easily overwhemed a current or past condition?* Current Past Explain your memory loss, confusion, easily overwhelmed condition in detail including treatment received.*Are you currently seeing a medical practitioner other than routine annual visit?* Yes No Explain why you are seeing a medical practitioner… Massage ConsentConsent to receive massage therapy*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 other 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 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. I Agree and consent to receiving a massageAre you age 18 or older?* Yes No Parent or Legal Guardian ConsentSince you are a minor, your parent or legal guardian will need to sign a consent form. If they have not already done so. Please ask them to see one of our spa coordinators to request the consent form. Thank You! Please click the submit button below…