Questionnaire

First Name

Last Name

Address

Phone

Date Of Birth

Employer

Occupation

Emergency Contact

Phone

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 Explain

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?

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

Additional details:

Respiratory

Additional details:

Circulatory

Additional details

Additional details:

Skin

Additional details

Nervous System

Additional details

Other

Additional details

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.*

Signstur

Date

Before Your Appointment

Please check any that apply to you:

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