Massage Therapy Health History


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

Massage Therapy Health History

Personal Health Information Name

Date of Birth Home Phone Work Phone Cell Phone

Address 1 Address 2 Email

Emergency Contact Information Emergency Contact

Phone

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

Goals Rank your top three (1-3) health goals in order of their priority to you (1= highest priority): Enhancing athletic performance Improving cardiovascular circulation Increasing flexibility Injury care

Pain relief Strengthening Stress management Other:

Your Healthy Karma | (425) 890-0154 | www.yourkhealthykarma.com WA #00014750

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

Massage Therapy 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.

Your Healthy Karma | (425) 890-0154 | www.yourkhealthykarma.com WA #00014750

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

Massage Therapy Health History

Consent It is my choice to receive massage therapy. I realize that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm, or pain, or for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my well-being is being compromised. I understand that massage practitioners do not diagnose illness, disease, or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health status.

Signature:

Date:

Your Healthy Karma | (425) 890-0154 | www.yourkhealthykarma.com WA #00014750