Confidential Client Form

Myo Therapies LLC
Confidential Health Information Form

Name:______________________________________________________Date:______________________________

Address:_____________________________________City:________________State:____________Zip:__________

Home Telephone:___________________________Work Phone:____________________Cell#:_________________

Email:_________________________________________Referred by:_____________________________________

Date of Birth:_________________Sex: M /F Marital Status: M / S / W / D Spouse:________________________

Occupation:__________________________________Employer:__________________________________________

Person responsible for this account:_________________________________Health Plan:______________________

Subscribers Name:______________________________________ID#___________________Grp#:______________

Emergency Contact:_________________________________________________Phone #:_____________________

Physician’s Name:___________________________________________________Phone #:_____________________
The following information will be used to help plan safe and effective sessions.
Please answer the questions to the best of your knowledge.

Have you had a professional massage before? Yes / No
If yes, how often do you receive massage therapy?______________________________________
Do you have any difficulty lying on your front, back, or side? Yes / No
If yes, please explain:_____________________________________________________________
Do you have any allergies to oils, lotions, or ointments? Yes / No
If yes, please explain:_____________________________________________________________
Do you have sensitive skin? Yes / No
Are you wearing? ( ) contact lenses ( ) dentures ( ) hearing aid
Do you sit for long hours at a workstation, computer, or driving? Yes / No
If yes, please describe:____________________________________________________________
Do you perform any repetitive movement in your work, sports, or hobby? Yes / No
If yes, please describe:____________________________________________________________
Do you experience stress in your work, family, or other aspect of your life? Yes / No
If yes, how do you think it has affected your health?______________________________________
( )muscle tension ( ) anxiety ( ) insomnia ( ) irritability ( ) other:_____________________________
Is there a particular area of the body where you are experiencing tension, stiffness, pain, or other discomfort? Yes / No
If yes, please identify:_____________________________________________________________
Do you have any particular goals in mind for this massage session? Yes / No
If yes, please explain:_____________________________________________________________

Medical History
In order to plan a massage session that is safe and effective, I need some general information about your medical history.
Are you currently under medical supervision? Yes / No
If yes, please explain:_____________________________________________________________
Do you currently see a chiropractor? Yes / No If yes how often?_______________________________
List medicationsyou are taking:___________________________________________________________
____________________________________________________________________________________

Please check all that apply:

( ) contagious skin condition ( ) open sores or wounds ( ) easy bruising
( ) recent accident or injury ( ) recent fracture ( ) recent surgery
( ) artificial joint ( ) sprains/strains ( ) current fever
( ) swollen glands ( ) allergies/sensitivity ( ) heart condition
( ) high or low blood pressure ( ) circulatory disorder ( ) varicose veins
( ) atherosclerosis ( ) abdominal ( ) breast lumps
( ) bunions ( ) chest pain ( ) digestive problems
( ) fatigue (chronic) ( ) hamstring problems ( ) hernia
( ) infertility ( ) lung problems ( ) orthodontia
( ) plantar fascitis ( ) sacral problems ( ) shoulder problems
( ) back pain ( ) breast pain ( ) bursitis
( ) colic ( ) dizziness ( ) fibromyalgia
( ) hay fever ( ) hip pain ( ) jaw / TMJ problems
( ) migraines ( ) osteoporosis ( ) pregnant
( ) sciatica ( ) sinus problems ( ) arthritis
( ) bed wetting ( ) breast implants ( ) butt pain
( ) constipation ( ) ear problems ( ) fractures old / new
( ) head aches ( ) hip replacement ( ) joint replacement
( ) knee problems ( ) pain ( ) prostrate problems
( ) scoliosis ( ) tennis elbow ( ) asthma
( ) bone spurs ( ) bronchitis ( ) carpal tunnel syndrome
( ) diaphragm pain ( ) edema ( ) gall bladder problems
( ) heart problems ( ) incontinence ( ) liver problems
( ) numbness ( ) pelvic problems ( ) rib problems
( ) shin splints ( ) tinnitus ( ) cancer

Please clarify:_________________________________________________________________________
____________________________________________________________________________________

Please use the letters and intensity scale provided to identify the symptoms you are feeling today:
P= pain or tenderness S= joint or muscle stiffness N= numbness or tingling
Intensity – No pain – 0 1 2 3 4 5 6 7 8 9 10 – Unbearable pain

The legal stuff:
.
I understand that bodywork treatments (IE – Bowenwork, massage, active isolated stretching,) are provided for the basic purpose of relaxation, stress reduction and relief of muscular tension spasm or pain and to increase circulation and energy flow. I am aware of the benefits and risk of bodywork and it is my choice to receive bodywork. I understand that bodywork is hands on treatment and I give my permission for the practitioner to touch my body. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure may be adjusted to my level of comfort. I further understand that bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified specialist for any mental or physical ailment that I am aware of. I understand that the bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any ailment, and that nothing said in the course of the session should be construed as such. Because bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist; part should I fail to do so. I understand there is no implied or stated guarantee of success or effectiveness of individual techniques or series of appointments. It is understood that the treatments are my personal responsibility and agree to pay at the time of service, unless other arrangements have been made. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the visit, and I will be liable for payment for the scheduled appointment.
Client signature_____________________________________________________Date___________
Consent to Treat a Minor
Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

By my signature below, I hereby authorize Myo Therapies to administer bodywork techniques to my child or dependent as they deem necessary.

Signature of parent or guardian____________________________________________Date___________

 

 

Draping will be used during the session – only the area being worked on will be uncovered. If at any time you feel uncomfortable with the draping please inform the practitioner immediately.
The following may sometime occur during bodywork treatments. They are normal responses. The need to move or change position, sighing, yawning, change in breathing,stomach gurgling, emotional feelings and/or expressions, movement of intestinal gas, energy shifts, falling asleep, and memories are often felt during a session. Trust your body to express what it needs to.

©2013 Myo Therapies LLC

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