Massage Therapy Wellness Chart - Cornerstone Physical Therapy, Inc.

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Massage Therapy Wellness Chart
Nicole Smith 11218, Kayla Simmons 14640, and Lizzie Matuszewski 13759
Name: _______________________________Address: _______________________________State:___ Zip:______
Phone: ___________ Email address: __________________________________Occupation: __________________
How did you hear about us: ______________________________________________________________________
Thank you for choosing Cornerstone Physical Therapy and Nicole Smith and/or Kayla Simmons and/or Lizzie Matuszewski
for your massage services. Nicole Smith and/or Kayla Simmons and/or Lizzie Matuszewski and Cornerstone PT are not
responsible for your personal belongings, so please secure them in a safe place. It is your responsibility to inform your
therapist, Nicole Smith and/or Kayla Simmons and/or Lizzie Matuszewski, of any pre-existing conditions, limitations or
specific sensitivities, including your massage preference. The massage is customized to your needs, so please be specific
about desired pressure and comfort levels. Please note that modest draping will be used during each session ensuring that male
and female genitalia and women’s breasts will not be exposed or massaged at any time. You understand and voluntarily accept
any risks of which you have been advised about associated with your massage, and use of the company’s facilities. You
hereby release Nicole Smith, Kayla Simmons, Lizzie Matuszewski, Cornerstone PT and all of the foregoing personnel and
entities from all liability including: failure to inform Nicole Smith and/or Kayla Simmons and/or Lizzie Matuszewski of
medical history, and any discomfort during the session, any injury (personal, bodily or mental) economic loss or damage to
you resulting there from. You also understand that your therapist, Nicole Smith and/or Kayla Simmons and/or Lizzie
Matuszewski, may require a physician’s medical release prior to continuing treatment if necessary. Cancellations made with
less than 24 hours notice will result in a fee of 40% of the massage cost. After three cancellations with less than 24 hours
notice, we will require a credit card on file in order to schedule any more massage appointments.
Signature: _________________________________________________ Date: __________________________
Please complete the following information to ensure a safe and comfortable massage experience:
___
Blood Clots
___
Fibromyalgia/Lupus
___
Osteoporosis
___
Cancer
___
Infections
___
Thyroid Disease
___
Diabetes
___
Varicose Veins
___
Stroke History
___
Immune System Deficiencies ___
Heart Problems
___
Headaches
___
High/Low Blood Pressure
___
Osteoarthritis
___
Arthritis
___
Insomnia
___
Pain
(joint/muscle/nerve)
Explanation(s): _______________________________________________________________________________________________
List and explain: Surgeries, injuries, illnesses: ______________________________________________________________________
___________________________________________________________________________________________________________
Allergies (scents, oil, lotions, nuts, etc): _________________________ Sensitive to Heat? Yes No
Pregnant? Yes No
List all current medications: _____________________________________________________________________________________
Have you ever experienced pain, numbness, tingling, swelling or fatigue in the last 3 months? Explain:
Yes
No
____________________________________________________________________________________________________________
List daily activities that are inhibited by your current condition/pain? ____________________________________________________
Are you comfortable with having therapeutic massage on the following areas:
Gluteal Region Yes No Abdomen Yes No Pectoral Yes No Feet Yes No Face/Head Yes No
Desired Pressure:
____ Light
____ Medium/Firm
____ Deep

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