Assessment First Remedial Massage Therapy Client Information And Consent Form (Page 3 of 4) in pdf

Assessment First Remedial Massage Therapy Client Information And Consent Form Page 3

ASSESSMENT FIRST REMEDIAL MASSAGE THERAPY - Marie Trafford, RMT

Lifestyle Questions

Regular eating habits

!Yes !No

Do you take vitamins:

Do you take prescribed medications:

!Yes !No

Frequency: ________________________

_____________________________________________________________

Type: ____

____________________________________________________________________

Regular exercise

!Yes !No

___________________________

Frequency: _____________________

Type:

High Stress

!Yes !No IF YES:

At home

At work

Both

Have you received care from any of the following: (circle)

physiotherapist

chiropractor

massage therapist

naturopath

other:

Have you had surgery in the past?

If yes, for what?

Have you had any fractures/sprains in the past?

If yes, where?

Have you had any serious illnesses in the past?

If yes, what?

Did the current injury result from a motor vehicle accident or workplace injury? Yes No

Please read carefully, and sign.

I attest that the information I have provided is true and complete to the best of my knowledge.

I understand the information I have provided on this form is confidential and will not be released without my

written consent.

I consent to therapeutic massage treatment by the above named massage therapist.

I also understand that I am responsible for any charges incurred in the course of my treatment.

PRINT NAME: __________________________

SIGNATURE: __________________________

DATE: ________________________________

Assessment First Remedial Massage Therapy Client Information And Consent Form Page 3