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NEW CLIENT EVALUATION

Birthday
Month
Day
Year

Ex: High/low blood pressure, Diabetes, etc. Please indicate "N/A" if not applicable

Ex: Shingles, Ringworm, AIDS, etc. Please indicate "N/A" if not applicable

Please check your hands and feet prior to answering as many clients are unaware and these are HIGHLY TRANSMITTABLE.

If you would like tell me more about any of the conditions you noted above please do so here. For example: acute, chronic, frequency, known triggers, etc.

List all known food and drug allergies (even if you don't think it applies to massage). If "none" please note.

Have you had a professional massage before?
Yes
No, this is my first

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/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 medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the scheduled appointment. Understanding all of this, by signing my name below, I give my consent to receive care.

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