Roxanne Hollenbeck ~ Licensed Massage Therapist/EMT North Country Therapeutic Massage  2060 Harwood Drive Sandy Creek, New York 13145 (315) 387-3529 FYI:  An accurate health history ensures that it is safe for you to receive massage therapy, and it helps the therapist determine a proper treatment plan. All information gathered on this form is confential. Your written concent is required before any of this information can be released. Massage can help many conditions, however there are some conditions where massage is contraindicated.

Current Health Information

Name:_________________________________________________________________________________________________ Date:_______________________________________________________________
Address:_______________________________________________________________________________________________ Phone:_________________________________ Cell:_________________________
Date of Birth:____________________________________________ Occupation:______________________________________ Referred by:__________________________________________________________

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 _________________________

Reason for today’s visit: (circle) Relaxation / Sore Muscles / Chronic Pain / Stress /
Have you received massage before? ____________
Do you have any limited range of motion? Left Arm / Right Arm / Left Leg / Right Leg / Left Foot / Right Foot / Head &/or Neck Rotation: to the Left / Right /Forward /Backward
List Previous Injuries / Date of occurance: ____________________________________________________________________________________________________________________

Circle Issues You Are Experiencing:             Musculo-Skeletal Headaches Joint stiffness/swelling Spasms/cramps Broken/fractured bones Strains/sprains Back, hip pain Shoulder, neck, arm, hand pain Leg, foot pain Chest, ribs, abdominal pain Problems walking Jaw pain/TMJ Tendinitis Bursitis Arthritis Osteoporosis Scoliosis Bone or joint disease Other: ___________________ Circulatory and Respiratory Dizziness Shortness of breath Fainting Cold feet or hands Cold sweats Swollen ankles Pressure sores Varicose veins Blood clots Stroke Heart condition Allergies Sinus problems Asthma High blood pressure Low blood pressure Lymphedema Lymph Node Removal_________ For clients who need mobility assistance, please give your height: ________ weight: ________ Skin Rashes Allergies Athlete’s Foot Warts Moles Acne Cosmetic surgery Other: ___________________ Digestive Nervous stomach Indigestion Constipation Intestinal gas/bloating Diarrhea Diverticulitis Irritable bowel syndrome Crohn’s Disease Colitis Adaptive aids Other: ___________________ Nervous System Numbness/tingling Twitching of face Fatigue Chronic pain Sleep disorders Ulcers Paralysis Herpes/shingles Cerebral Palsy Epilepsy Chronic Fatigue Syndrome Multiple Sclerosis Muscular Dystrophy Parkinson’s disease Spinal cord injury Other: ___________________ Reproductive System Pregnancy: Current Previous PMS Menopause Pelvic Inflammatory Disease Endometriosis Hysterectomy Fertility concerns Prostate problems Other Loss of appetite Forgetfulness Confusion Depression Difficulty concentrating Drug use ____________ Alcohol use __________ Nicotine use __________ Caffeine use ______________ Hearing impaired Visually impaired Burning upon urination Bladder infection Eating disorder Diabetes Fibromyalgia Post/Polio Syndrome Cancer Infectious disease (please list)     Other congenital or acquired disabilities (please list)     Surgeries (when/what for)

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.