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Medical Form

**Please remember to always consult your doctor if you are unsure if massage is right for you.

First name*

Last name*

Email*

Phone

Age*

Referred by

Occupation*

Emergency Contact*

Emergency Contact Phone Number*

Stress/Anxiety/Depression

Muscle Weakness

Bleeding Disorder

Neuropathy

Blood Clots

Osteoarthritis

Bruise Easily

Osteoporosis

Bursitis

Phlebitis/Vericose Veins

Diabetes

Rheumatoid Arthritis

Fibromyalgia

Sciatica

Hearing Loss

Seizures

High Blood Pressure

Stroke/CVA

Low Blood Pressure

Tuberculosis

Kidney Disease

Tendinitis

Multiple Sclerosis

TMJ

Dizziness

Vision Impairment

Skin Conditions

Heart Conditions

Digestion Conditions

Endocrine Disorder/Thyroid Issues

Respiratory Disorder

Autoimmune Disease

Areas of Swelling

Frequent Headaches

Neurological Conditions

Areas of Numbness or Decreased Sensation

Areas of Broken Skin?

If yes, WHERE?

Any infectious or contagious conditions? FUNGUS, HIV, SHINGLES, WARTS,etc

Any allergies or hypersensitivities?

Are you pregnant? If yes, how far along?

List current medications you are taking

Any joint replacements?

Any inplants PACEMAKER, insulin pump, etc

Currently receiving any medical or mental health interventions?

Describe any injuries or health conditions

Have you had professional massage?

If yes, when was your last one?

What is your reason for seeking massage?

How much pressure do you prefer? LIGHT, MEDIUM FIRM

PLEASE LIST any areas of stiffness, numbness, tingling, or pain.

By signing this document, I acknowledge I understand the risks and benefits of massage and that I have completed this form accurately and truthfully to the best of my knowledge. I also agree to inform the massage therapist of any health or medical changes.

Signature*

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99 Moose Meadow Lane

PO Box 24

Waldoboro, ME 04572

adminoperations@downeastschoolofmassage.net

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