Richard
A. Yost, Licensed Massage Therapist
Name: ________________________________ Today’s Date: ___________ Your Birth Date: _________
Address: ______________________________ Male ____ Female ____ Height: ______ Weight ________
_____________________________________ Emergency Contact: ______________________________
Phone Day ____________ Eve ____________ Emergency Contact Phone: _________________________
Family Physician: _______________________ Date of last physical Exam: ____________________
___ Frequent headaches ___Bloated Stomach ___High Blood Pressure
___Neck Pain/Tightness ___Constipation ___ Low Blood Pressure
___Lumps or Swelling ___ Loose Bowels ___ Swelling in Feet or Ankles
___ ________________ ___ _________________ ___ Leg Cramps
___ ______________________
___ Wear Glasses ___ Last Period __________ ___ Bruise Easily
___ Wear Contacts ___ Lump or Pain in Breasts ___ Open Cuts or Sores
___ ________________ ___ Pregnant Due ________ ___ Skin Allergies
___ Menstrual Cramps ___ Tender Areas on Skin
Musculoskeletal ___ ____________________ ___ _________________
___ Aching Muscles
___ Aching Joints Male/Genito/Urinary Nervous System
___ Low Back Pain
___ Shoulder Pain ___ Painful/Slow Urination ___ Difficulty Relaxing
___ Painful Feet ___ Nighttime Urinary Frequency ___ Difficulty Sleeping
___ ________________ ___ _______________________ ___ ____________________
___ ________________
___ ________________ Respiratory Other
___ Asthma/Bronchitis ___ _____________________
___ Easily Out of Breath ___ _____________________
Accidents you have had – automobile? childhood? industrial? _______________________________
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Problems diagnosed by a doctor – Circle if currently being treated, check if treated in the past.
___ Broken bones (which bones) ___ Diabetes ___ Tumors/cancer (where)
_________________________ ___ Heart Disease (what type) __________________________
___ Sprain/dislocation (which joint) _______________________ ___ Tuberculosis
___________________________ ___ Kidney/bladder/prostate ___ Epilepsy
___ Arthritis/Rheumatism ___ Stroke/CVA ___ Ulcer/colitis/diverticulitis
___ Fibrositis/fibromyalgia ___ Sciatica ___ HIV/AIDS
___ Bursitis ___ Hypertension ___ _____________________
___ Standing ___ Stooping ___ Kneeling ___ Driving
___ Sitting ___ Bending ___ Lifting ___ Other (list below)
Which movements cause a problem? _______________________________________________________
Occupation: _________________________ Sports: _________________________________________
Your Current Problem: ___________________________________________________________________
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Are you currently taking any medications? __________ Name: _____________________________________
Do you have a psychiatric illness we should be aware of? _______ Describe: __________________________
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Are you currently seeing another therapist? ____________ If so, it is your responsibility to notify him/her that you are receiving this treatment.
Brief summary of psychological, and/or somatic treatments you have had: ___________________________________________________
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List any meditative practices you do (yoga, tm, t’ai chi, etc._ _____________________________________________________________
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List 3 current positive situations or relationships List 3 current negative situations or relationships
______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ _______________________________________
Please carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, energetic/emotional/somatics may be contraindicated. A referral from your primary care provider may be required to service being provided.
“If I experience any pain or discomfort during a session, physical or emotional, I will immediately inform the practitioner so that the pressure and strokes may be adjusted to my level of comfort during the session. I further understand that these treatments should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician for any ailment that I am aware of. Because somatics/movement manipulations 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 forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me, the client, will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I will also give the practitioner 24 hours prior notice of appointment cancellation, or I will be liable for payment in full. I understand that payment is due at the time the appointment is booked.
Client Signature _____________________________ Date _____________________