zeftera.ru.

Health History

Health History

Name____________________________________________ Date ___________________
Address ___________________________________________ Phone ___________________
Occupation ______________email
Date of Birth___________
Sports/Physical activities/hobbies _________________________________________________
How did you hear about Royal Orchid Thai Spa, who referred you?_____________________
Do you have insurance benefits for massage therapy? If so, which company for receipt purposes.__________________Preferred pressure for your massage: Soft__Medium__Deep__
The following information will be used to help plan safe and effective massage sessions
Please answer to the best of your knowledge.
1. Have you had professional massage before? Yes No
2. Do you have any difficulty lying on your front, back or side? Yes No If yes, please explain _____________________________________________
3. Do you have allergic reactions to oils, lotions, aliments, liniments or
other substances put on your skin? Yes No
If yes, please explain __________________________________________
4. Do you wear contact lenses ( ) dentures ( ) a hearing aid ( ) ?
5. Do you sit for long hours at a workstation, computer or driving? Yes No
If yes, please explain __________________________________________
6. Do you perform any repetitive movement in your work, sports, and hobby? Yes No
If yes, please explain __________________________________________
7. 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 ( )
8. Is there a particular area of the body where you are experiencing tension,
stiffness or other discomfort? Yes No
9. Do you have any particular goals in mind for this massage session? Yes No
If yes, please explain ___________________________________________
10. Are you currently under medical supervision? Yes No
If yes, please explain __________________________________________
11. Are you currently taking any medication? Yes No
If yes, please explain __________________________________________
12. Please check any condition listed below that applies to you:
Contagious skin condition, Joint disorder, Rheumatoid arthritis, Easy bruising, Open sores or wounds, Osteoporosis, Recent accident or injury, Epilepsy, Current fever, Headaches, Swollen glands, Cancer, Diabetes
Decreased sensation, Heart condition, High / low blood pressure, Allergies
Circulatory disorder, Artificial joint, Varicose veins, Atherosclerosis, Phlebitis, Recent surgery …………………………………………..
Comments:
13. Is there anything else about your health history that you think would be useful for your massage therapist to know?_______________________________________________________
14. For Women: Are you pregnant? Yes No If yes, how many months? _____________
I understand that these massage sessions are for general wellness purposes and that I should see a doctor or other appropriate health care provider for diagnosis and treatment of any suspected medical problem. Also, that it is my responsibility to keep my massage practitioner informed of any changes in my health, and any medications that I may begin to take in the future and I understand that there shall be no liability on the practitioner‘s part should I fail to do so.

Please read our SPA Policy and confirm by Signature Below .

Signature_____________________________ Date_________________________