North Country Therapeutic Massage 
2060 Harwood Drive
Sandy Creek, New York 13145
(315) 387-3529 or DURELAX

Roxanne Hollenbeck
Licensed Massage Therapist
Patient Information


Patient Name _____________________________________________________________________________ Date _____________
Address __________________________________________________________________________________Phone____________
Date of Birth ____________________ Occupation _________________________________________________________________
Referred by: ________________________________________________________________________________________________
Have you ever received Massage Therapy before? _________________________________________________________________
  Primary Health Care Provider
Name _________________________________________________________ Phone __________________Fax ________________
Address ___________________________________________________________________________________________________
 I give the Massage Therapist permission to consult with my referring health care provider regarding my heath and treatment.
Signed ______________________________________________________________________ Date _________________________

 Current Health Information

Reason for today’s visit: ______________________________________________________________________________________

What are your goals for receiving Massage Therapy? _______________________________________________________________
List all conditions currently monitored by a Health Care Provider: _____________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
List the medications you took today (include pain relievers and herbal remedies) __________________________________________
___________________________________________________________________________________________________________
List all medications you take on a regular basis (include pain relievers and herbal remedies) _________________________________ ___________________________________________________________________________________________________________
 List Daily Activities
Work _____________________________________________________________________________________________________
Home _____________________________________________________________________________________________________
Recreational ________________________________________________________________________________________________
What activities of your daily life are you unable to do? ______________________________________________________________
__________________________________________________________________________________________________________

 Health History
 List and Explain. Include dates and treatment received.
Surgeries __________________________________________________________________________________________________
Accidents __________________________________________________________________________________________________
Major Illnesses ______________________________________________________________________________________________

Musculo-Skeletal
o Headaches
o Joint stiffness/swelling
o Spasms/cramps
o Broken/fractured bones
o Strains/sprains
o Back, hip pain
o Shoulder, neck, arm, hand pain
o Leg, foot pain
o Chest, ribs, abdominal pain
o Problems walking
o Jaw pain/TMJ
o Tendinitis
o Bursitis
o Arthritis
o Osteoporosis
o Scoliosis
o Bone or joint disease
o Other: ___________________

Circulatory and Respiratory
o Dizziness
o Shortness of breath
o Fainting
o Cold feet or hands
o Cold sweats
o Swollen ankles
o Pressure sores
o Varicose veins
o Blood clots
o Stroke
o Heart condition
o Allergies
o Sinus problems
o Asthma
o High blood pressure
o Low blood pressure
o Lymphedema
o Lymph Node Removal_________
 Skin
o Rashes
o Allergies
o Athlete’s Foot
o Warts
o Moles
o Acne
o Cosmetic surgery
o Other: ___________________

Digestive
o Nervous stomach
o Indigestion
o Constipation
o Intestinal gas/bloating
o Diarrhea
o Diverticulitis
o Irritable bowel syndrome
o Crohn’s Disease
o Colitis
o Adaptive aids
o Other: ___________________

Nervous System
o Numbness/tingling
o Twitching of face
o Fatigue
o Chronic pain
o Sleep disorders
o Ulcers
o Paralysis
o Herpes/shingles
o Cerebral Palsy
o Epilepsy
o Chronic Fatigue Syndrome
o Multiple Sclerosis
o Muscular Dystrophy
o Parkinson’s disease
o Spinal cord injury
o Other: ___________________

 Reproductive System
o Pregnancy:
   o Current
   o Previous
o PMS
o Menopause
o Pelvic Inflammatory Disease
o Endometriosis
o Hysterectomy
o Fertility concerns
o Prostate problems

Other
o Loss of appetite
o Forgetfulness
o Confusion
o Depression
o Difficulty concentrating
o Drug use _________________
o Alcohol use ______________
o Nicotine use ______________
o Caffeine use ______________
o Hearing impaired
o Visually impaired
o Burning upon urination
o Bladder infection
o Eating disorder
o Diabetes
o Fibromyalgia
o Post/Polio Syndrome
o Cancer
o Infectious disease (please list)
   __________________________
o Other congenital or acquired disabilities (please list) _______
  __________________________
o Surgeries ________________
o Other: ___________________

For clients who need mobility assistance, please give your
height: ________ weight: ________


I, ________________________, (patient) understand that massage therapy provided by North Country Therapeutic Massage is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch.

The general benefits of massage, possible massage contraindications and the treatment procedures have been explained to me. I understand that massage therapy is not a substitute for medical treatment or medications, and that it is recommended that I currently work with my Primary Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications, and that spinal manipulations are not part of massage therapy.

I have informed the massage therapist of all my known physical conditions, medical conditions and medications, and I will keep the massage therapist updated on any changes. I understand that there shall be no liability on the practitioner’s part due to my forgetting to relay any pertinent information.

If I experience any pain or discomfort during the session, I will immediately communicate that to the therapist so the treatment can be adjusted.

I also understand that the Massage Therapist has ZERO tolerance for any sexual innuendos/intentions, and if at any time during the session this occurs, treatment ends immediately with full payment expected.

I understand these policies and agree to abide by them.

_______________________________________________   _______________________
Patient Signature                                                                      Date
To save time you may print this form and fill it out prior to your appointment.


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