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Bodies in Balance RMT Massage

HEALTH FORM

Print & fill out at home or fill form at my office

PDF Form....click here

 

HEALTH FORM

Your answers to the following questions will be kept confidential.  They will be seen only by myself and are required by law so that I may provide you with better care.  Bodies in Balance will NEVER sell or give away any information of any kind to anyone else.

Name___________________________________      Date___________________________

Address____________________________________Phone: (Best # to call you on)______________________

City__________________________________ Province_____ Zip______________

Age___ D.O.B.____/____/____ Sex___  Pregnant?____  E-Mail (If I don’t have it ) _____________________

Occupation_________________________ What do you do for exercise?_______________________________

For relaxation?_________________________________ Have you received previous massage work?  _______

Allergies?_______________________________  Drugs(prescription/recreational)?_________________ ______________________________________

Pressure level ~~~Gentle ___ Work it out but don’t hurt me ___  Deep (Really get in there :)_____

Any major traumas you have had to your body  (e.g. accident, fall, etc.).
Please include ALL muscle, bone or joint injuries even if not recent : _______________________________________

_______________________________________

_______________________________________


Please use the chart to indicate areas of discomfort or desired areas to work on.>

Is there anything else I should know?

________________________________________________________________________

The following may sometimes occur during massage.  They are normal responses to relaxation and/or touch, and you need not be embarrassed nor feel you should suppress them.   Movement or release of intestinal gas - crying - laughing - strong emotions - sighing - groaning - yawning - softening of muscle tissue - cognitive or felt memories - stomach gurgling - need to move or change position.

At any time during your session please let me know if there is anything I can do to help you feel more comfortable.
YOU ARE IN CONTROL ~~~  ALWAYS TELL ME IF SOMETHING IS WRONG!

I understand that the services provided are not a replacement for medical or psychological care and that any information provided by Linda Powell, RMT is not prescriptive or diagnostic in nature and is for educational purposes only.   

 

Client's Signature_____________________________                 Date ____/____/____