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Comments:_____________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific conditions, massage may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that the massage I receive is for the purpose of relaxation & relief of muscular tension. If I experience any pain or discomfort, I will immediately inform the practitioner so that the pressure and/or stroke may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I should see a physician or qualified medical specialist for any physical or psychological ailment I am aware of. I understand that massage practitioners are not qualified to diagnose, prescribe, or treat any physical or mental illness & nothing said in the course of the session should be construed as such. Massage should not be performed under certain medical conditions. I affirm that I have stated all my known medical conditions CHNKWKS .øÿÿÿÿTEXTTEXT FDPPFDPP"FDPCFDPC$STSHSTSH&STSHSTSH&2SYIDSYIDP&SGP SGP d&INK INK h&BTEPPLC l&BTECPLC „&FONTFONTœ&tSTRSPLC ':PRNTWNPRJ'FRAMFRAMZ+ˆTITLTITLâ+DOP DOP ô+(Name:____________________________________ Ph:( )__________ Date of Birth___________ Address:__________________________________________________________________________ ______________________________________Email_______________________________________ Referred by:__________________________________________ Ph:( )______________________ In case of Emergency:__________________________________ Ph: ( )_____________________ General & Medical Information __Yes __No Have you ever experienced a professional massage/bodywork session ? If you answer  yes to any of the following questions, please explain as clearly as possible. __Yes __No Do you frequently suffer from stress? __Yes __No Are you Pregnant ? __Yes __No Do you experience frequent headaches? __Yes __No Are you wearing contacts? __Yes __No Are you epileptic? __Yes __No Are you diabetic ? __Yes __No Do you have tension or soreness in a __Yes __No Do you suffer from back In a specific area? pains anywhere? __Yes __No Do you have numbness or stabbing __Yes __No Have you ever had Pains anywhere ? surgery? __Yes __No Do you have high blood pressure? __Yes __No Are you sensitive to touch/ & answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile & understand that there shall be no liability on the practitioner s part should I forget to do so. Client signature__________________________________________________ Date__________________________ CLIENT INFORMATION __Yes __No Have you had any broken (°ü¬^šœ<øð0 " $  8 N * 68&8¦Âô´t6.P®°t v x z | !üüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüüôÌ ,2‚"'(Š  Û)Û @·S ·(2‚"'(Š  Û)Û @·S · šh®t x |   ¢ ! !îÜÐÜÐƤ”„Æ "ø|"  "0à" " "hC" $Š "   "  "PS"  "ˆ¶"  ´ƒÿÿÿÿ´ƒ "ð” " tt !" !$`´ƒ,Times New RomanCopperplate Gothic Boldÿ=R " " "¤øÃö ä ,,K KŠôèHP DeskJet 722CœXCï€d,,DINU"4$@$´·$˜$$˜$!winspoolHP DeskJet 722CLPT1:Fÿÿÿ"|¾"€‘"À¸r"i"ð` "ð``""A."@ÿÿÿ"|¾"ðù"À¸r"8Ô"ð` "ð``"."Untitled("àŽ"ø|"k"ø|| (" cribe, or treat any physical or mental illness & nothing said in the course of the session should be construed as such. Massage should not be performed under certain medical conditions. I affirm that I have stated all my known medical conditiþÿ ÿÿÿÿ²Z¤ žÑ¤ÀO¹2ºQuill96 Story Group Classÿÿÿÿô9²qy¹2ºy¹2ºy¹2º