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Have broad knowledge
- Dr. shivam sanadhya
First Name
Your Full Name
Last Name
Address
Phone
(123) 456-7890
Date Of Birth
Employer
Occupation
Emergency Contact
Relationship
Referred By
Email
Is This Your First Professional Massage?
If No, How Frequently Do You Get A Massage?
What Do You Hope To Accomplish From Today's Massage?
Are You Aware Of Any Tension Holding Spots In Your Body?
If Yes, Location(S)
Describe Any Surgeries, Hospitalizations, Accidents Or Injuries You Have Had:
Less Than 5 Years Ago:
More Than 5 Years Ago
What Kind Of Care Did You Receive For Your Accidents Or Injuries?
Do You Feel That You Have Recovered From These Events?
Please Explain:
Do You Have Any Chronic, Ongoing Pain That You Deal With On A Regular Basis?
Please Explain
Describe What Activities Cause This Pain And/or Make It Worse
Are You Receiving Any Other Type Of Medical Treatment?
Please List Any Medication (Vitamins, Herbs Or Pharmaceutical) Taken Now Or At Regular Intervals (Include Explanation Of What Medication Is Used To Treat)
Are You Currently Under The Care Of A Physician?
Whom?
Please List Reason(S)
Are There Any Other Health Concerns You Wish To Discuss Today?
If Yes, Please Describe:
Are you currently experiencing any of the following conditions?
Flue or Cold
Infection
Inflammation
Contagious Disease
Fever
Additional details:
Please check any of the following conditions below that currently affect you or that you have experienced in the last 5 years.
Musculoskeletal
Fibromyalgia
Option 2
Option 3
Option 4
Option 5
Respiratory
Pneumonia
Trouble Breathing
Sinusitis
Dizziness
Asthma
Other
Circulatory
Anemia
Low Blood Pressure
Heart Condition
Raynaud's Disease
Hemophilia
Blood Clots/Phlebitis
Hypertension
Varicose Veins
Diabetes
Additional details
Ulcers
Gallstones
Irritable Bowel Syndrome
Colitis
Hepatitis
Crohn's Disease
Diarrhea
Gas/Bloating
Indigestion
Skin
Fungal Infections
Acne
Impetigo
Dermatitis/Eczema
Psoriasis
Open Wound Or Sore
Rashes
Warts/Moles
Athletes Foot
Nervous System
ALS
Bell's Palsy
Stroke
Numbness/tingling/twitching
Multiple Sclerosis
Neuritis
Trigeminal Neuralgia
Parkinson's Disease
Spinal Cord Injury
Seizure Disorders
Insomnia
Grief Process
Pregnancy
Lupus
Postoperative Situation
Anxiety/Panic Attacks
Cancer
Chronic Fatigue
Kidney Disease
Edema
PMS
Substance Abuse
HIV/AIDS
Bladder Infection
The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications bones. I further understand that message therapy is not a substitute for medical attention or examination. I take responsibility for altering my practitioner to any physical, mental or emotional changes that occur with my health. I also understand that cancelled or missed appointment without 24 hours notice (medical emergencies excluded) may be charged in full for the price of the missed session.*
I Agree
Signstur
Date
Before Your Appointment
Please check any that apply to you:
HAVE YOU HAD A NEW OR WORSENING COUGH?
HAVE YOU HAD A FEVER?
HAVE YOU HAD A SHORTNESS OF BREATH?
HAVE YOU BEEN IN CLOSE CONTACT WITH ANYTHING WITH THESE SYMPTOMS OR ANYONE WHO HAS BEEN DIAGNOSEDE WITH COVID 19 IN THE PAST 14 DAYS?
By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless any of the massage practitioners at Massage and Cranial Release Therapy Center from any claims related thereto. I give my consent to receive treatment from any practitioner at this location 720 Avignon Dr suite 3 Ridgeland MS 39157
Signature
Date:
Parent or Guardian Signature (In case of Minor)
Milagros Altamirano LMT 1211
Massage Cranial Release Therapy Center
