Associated Bodywork & Massage Professionals MEMBER

Practitioner/Clinic Name: Veda King Blanchard/Rooted Arts
Contact Information: (862)202-6948; rootedarts@gmail.com

Client Contact Information
Client Name: ___________________________________ Date: ____________
Date of Birth: ____________ Gender: ____________

Address: _________________________________________________________________________

Phone: _______________________________________

Email: ___________________________________

Referred by: ___________________________________

Emergency contact: ____________________________

Phone: ___________________________________

Physician/Health-care Provider name: __________________________ Phone: ____________________
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? Yes ☐ No ☐
Do you have a physician referral/prescription? Yes ☐ No ☐

Massage Information
Have you ever received professional massage/bodywork before? Yes ☐ No ☐
How recently? ___________________________________
What types of massage/bodywork do you prefer? ___________________________________
What kind of pressure do you prefer? Light Medium Firm
What are your goals/expected outcomes for receiving massage/bodywork?

______________________________________________________________________________

________________________________________________________________________________

__________________________________________________________
How do you feel today?

______________________________________________________________________
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

_______________________________________________________________________________

________________________________________________________________________________
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? Yes No
Explain:
________________________________________________________________________________

________________________________________________________________________________
List the medications and supplements you currently take:
________________________________________________________________________________

_______________________________________________________________________________
Are you wearing contacts? Yes ☐ No ☐
Are you wearing dentures? Yes ☐ No ☐
Are you wearing a hairpiece? Yes ☐ No ☐
Are you pregnant? Yes ☐ No ☐

Health History
Have you had any injuries or surgeries in the past that may influence today’s treatment?

________________________________________________________________________________

___________________________________________________________________
Circle any of the following health conditions that you currently have (If you are unsure, please ask):

blood clots, infections, congestive heart failure, contagious diseases, pitted edema

Please answer honestly, as massage may not be indicated for the above conditions, and may, in some cases, be dangerous.
Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:
Current Past Muscle or joint pain _____________________________________
Current Past Muscle or joint stiffness _____________________________________
Current Past Numbness or tingling _____________________________________
Current Past Swelling _____________________________________
Current Past Bruise easily _____________________________________
Current Past Sensitive to touch/pressure _____________________________________
Current Past High/Low blood pressure _____________________________________
Current Past Stroke, heart attack _____________________________________
Current Past Varicose veins _____________________________________
Current Past Shortness of breath, asthma _____________________________________
Current Past Cancer _____________________________________
Current Past Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________
Current Past Epilepsy, seizures _____________________________________
Current Past Headaches, Migraines _____________________________________
Current Past Dizziness, ringing in the ears _____________________________________
Current Past Digestive conditions (e.g. Crohn’s, IBS) _____________________________________
Current Past Gas, bloating, constipation _____________________________________
Current Past Kidney disease, infection _____________________________________
Current Past Arthritis (rheumatoid, osteoarthritis) _____________________________________
Current Past Osteoporosis, degenerative spine/disk _____________________________________
Current Past Scoliosis _____________________________________
Current Past Broken bones _____________________________________
Current Past Allergies _____________________________________
Current Past Diabetes _____________________________________
Current Past Endocrine/thyroid conditions _____________________________________
Current Past Depression, anxiety _____________________________________
Current Past Memory Loss, confusion, easily overwhelmed _____________________________________

Comments:________________________________________________________________________

________________________________________________________________________________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 payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature: _____________________________________________________________

Date: ____________

Parent or Guardian Signature (in case of a minor): ___________________________________

Date: ____________