Massage Health History


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Your Healthy Karma www.yourhealthykarma.com (425)890-0154

Massage Health History

PERSONAL HEALTH INFORMATION Name Address 1 Address 2 Email

Date of Birth Home Phone Work Phone Cell Phone

EMERGENCY CONTACT INFORMATION Phone

Emergency Contact

Relationship

HEALTH HISTORY Please check (✓) all conditions that you are currently experiencing or have had in the last 10 days: Cardiovascular disease High blood pressure Low blood pressure Varicose veins Blood clots Lymphedema Scoliosis Joint disease Bone disease Tendonitis Plantar fasciitis Osteoarthritis Sprains/strains Other health conditions:

Asthma Sinus problems Shortness of breath Emphysema Cold/Flu COPD Jaw pain (TMJ disease) Muscular dystrophy Numbness/tingling Chronic pain Allergies Pregnancy # weeks:

Acne inflammation Skin rash Healing burns/scrapes/bruises Athlete's foot/fungal infection Warts Skin sensitivity Cancer Diabetes Lupus Lyme Disease Chronic Headaches Herpes/shingles Rheumatoid Arthritis

TREATMENT GOALS General intended outcomes for massage: Applications of massage are commonly intended to decrease pain and increase function, balance, and movement. Massage therapy can decrease tension and release restricted tissues through direct and indirect treatment applications. Massage therapy can relieve physical and emotional stress and create a state of relaxation. The degree and duration of intended outcomes may depend on a variety of factors. Massage therapy is intended to support the body’s natural healing functions and is not a substitute for appropriate medical care. Rank your top three (1-3) health goals in order of their priority to you (1= highest priority): Enhancing athletic performance

Pain relief

Improving cardiovascular circulation

Strengthening

Increasing flexibility

Stress management

Injury care

Other:

Karma Raad, LMT (425) 890-0154 WA #MA14750

Your Healthy Karma www.yourhealthykarma.com (425)890-0154

Massage Health History TREATMENT FOCUS

On the diagrams below, circle any areas of pain or tension that you would like to relieve through massage. Please mark an X over any area that you do NOT want touched.

As a massage therapist licensed in the State of Washington, my services are limited to the scope of practice as defined in the Revised Code of Washington (RCW.18.108) and Washington Administration Code (WAC-246-830). RCW 18.108.010 Definitions: "Massage" and "massage therapy" mean a health care service involving the external manipulation or pressure of soft tissue for therapeutic purposes. Massage therapy includes techniques such as tapping, compressions, friction, reflexology, Swedish gymnastics or movements, gliding, kneading, shaking, and fascial or connective tissue stretching, with or without the aids of superficial heat, cold, water, lubricants, or salts. Massage therapy does not include diagnosis or attempts to adjust or manipulate any articulations of the body or spine or mobilization of these articulations by the use of a thrusting force, nor does it include genital manipulation.

INFORMED CONSENT It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. Print Name:

Date:

Signature:

Karma Raad, LMT (425) 890-0154 WA #MA14750

Your Healthy Karma www.yourhealthykarma.com (425)890-0154

Massage Health History

CONSENT FOR MINORS UNDER 18 All persons under the age of 18 are required to have a parent or guardian fill out this section. By signing below, you agree that you are the parent or legal guardian of the minor receiving treatment(s) at our facility. You understand that you are required to remain at the facility/service location for the entirety of the minor’s treatment(s). You will also be required, if needed, to assist the minor in preparing for his/her treatment(s). We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor. You also agree that you have completed the Intake Form and have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatment(s). PLEASE PRINT CLEARLY I ____________________________________, certify that I am the parent or legal guardian of _____________________________, who is _________ years of age as of today. I have completed the Massage Health History Form for the above-mentioned minor and informed the therapist of all relevant medical history and concerns. I understand the scope of massage therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. I give permission for my minor child to receive treatment(s) at this facility and agree to all the above terms. Print Name:

Date:

Signature:

Relationship to Client:

Karma Raad, LMT (425) 890-0154 WA #MA14750