Lavande Difference
Services
Therapist
Policies
Forms
Contact Us
Lavande Difference
Services
Therapist
Policies
Forms
Contact Us
Health History
Prior to your first appointment please fill out Lavande's health history form
Name
*
First Name
Last Name
Email
*
Client Information and Medical History {Please fill out form below to the best of your knowledge. If space is provided please explain any medical conditions that apply to you, past and present} {Lavande requires written medical consent from a physician prior to massage therapy for certain medical conditions and all initial Pre-natal services}
*
Birthdate
Contact Information
*
Address/ Phone Number
Have you had a professional massage before?
*
Yes
No
Pressure Preference
*
Light
Medium
Firm
Overall Stress Level
*
0
1
2
3
4
5
6
7
8
9
10
Occupation
*
Hobbies/Sports/Fitness Routine
*
Are you sensitive to heat or cold?
*
No
Yes
Are you sensitive to pressure or bruise easily?
*
No
Yes
Do you have difficulty lying face down or up?
*
No
Yes
Are you claustrophobic?
*
No
Yes
Do you have dry or sensitive skin?
*
No
Yes
Do you have seasonal allergies or sensitive to scents?
*
No
Yes
Emergency Contact
*
Are you under the care of a physician or physical therapist?
*
If yes please provide Name and Phone Number or enter NA
Are you taking any medications or supplements?
*
If yes please list all below or enter NA
Are you allergic to anything?
*
If yes, please list all below or enter NA
{Women} Are you currently pregnant?
No
Yes
Have you had any previous surgeries?
*
No
Yes
List any surgeries below?
Do you currently have or have had in the past any broken bones or torn ligaments/tendons?
*
No
Yes
List any broken bones or torn ligaments/tendons below
Do you currently have any infectious/ contagious disease or open wounds/infections?
*
No
Yes
Please explain below:
Do you have any surgical implants or joint replacements?
*
No
Yes
List any implants or joint replacements below:
Do you have any herniated &/or bulging discs, or fused vertebrae?
*
No
Yes
Please list below:
Do you currently have any joint swelling?
*
No
Yes
List joint(s) affected and date or first occurrence below
Do you have osteoarthritis?
*
No
Yes
List joints affected below:
Have you been diagnosed with the any of the following? (check all that apply)
Rheumatoid Arthritis
Osteoporosis/Osteopenia
Scoliosis
Ankylosing spondylitis
Gout
Fibromyalgia
Do you currently suffer from chronic pain?
*
No
Yes
Do you have any numbness or decreased sensation anywhere?
*
No
Yes
Do you regularly get migraines &/or tension headaches?
*
No
Yes
Do yo have any of the following: (check all that apply)
Sciatica
Carpal Tunnel
Thoracic Outlet Syndrome (TOS)
Bursitis/Tendinitis
Tennis elbow (Lateral Epicondylitis)
Golfer's elbow (Medial Epicondylitis)
Rotator cuff injury
Frozen shoulder (Adhesive Capsulitis)
Plantar fasciitis
TMJ disorder
Shin splints
Have you ever dislocated or separated a joint?
*
No
Yes
Please check any of the following conditions that apply to you, past and present:
Check all that apply
Cardiac/Vascular disease
High Blood pressure (Hypertension)
Low Blood pressure (Hypotension)
Varicose Veins
Blood clots
Deep Vein Thrombosis (DVT)
Diabetes
Stroke
Heart Attack
Pacemaker
Epilepsy/Seizures
Have you been diagnosed with any of the following? (check all that apply)
Lupus
Multiple Sclerosis (MS)
Parkinson's
Do you currently suffer from any of the below conditions: check all that apply
Anxiety
PTSD
Sleep problems
Difficulty Breathing
COPD
Eczema
Psoriasis
Difficulty hearing or wear hearing aids.
Do yo currently have cancer or are in remission?
*
No
Yes
Please explain below, if currently under treatment please include oncologist's information:
Do you have any other medical conditions/injuries not previously listed?
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.
*
Signature/Date
I will make sound choices regarding my sessions’ plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised. I expect my practitioner to provide safe and effective treatment to the best of his or her skills and knowledge.
*
Signature/Date
Thank you!
Health History
Utah Massage Waiver
Lava Shell Consent
Soft Cupping Consent
Prenatal Massage Form
Kinesio-tape Consent
