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Name____________________________________________________Phone_______________________________
Address___________________________________________ e-mail______________________________________
City_______________________ State_____________ Zip Code_______________ Date of Birth________________
Occupation: ________________________________________ Referred by:________________________________
Emergency Contact: _______________________________________Phone:_______________________________  

General and Medical Information:                                                    Circle areas of pain or discomfort 
Date of most recent massage_______________________
What did you like or dislike about it?__________________
_______________________________________________ 
Rate your stress level:
0   1   2   3   4   5   6   7   8   9   10                  
No stress                                   STRESSED
Rate your pain level: 
 	0   1   2   3   4   5   6   7   8   9   10
No pain		       Worst pain ever 
Please circle any health issue that applies to you in the list below:

Additional comments regarding
Your health & well-being:
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________

Frequent Headaches
Joint stiffness/swelling
Arthritis
Osteoporosis
Bursitis
Tendonitis
Scoliosis
TMJ/Jaw pain
Back Pain
Numbness In:____________
Stabbing pain
Rashes
Acne
Athlete’s foot
Open wounds/cuts
Allergies:_______________
_______________________

Diabetic  I or  II
Heart disease
Fibromyalgia
Multiple Sclerosis
Muscular Dystrophy
Epilepsy
Parkinson’s Disease
Alzheimer’s Disease
Recent surgery (within 6 wks)
Edema (swelling, water retention)
Lymphedema
High Blood pressure treated
High blood pressure untreated
Asthma
Cancer
Pregnancy ________ Months
Other: __________________

PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING 
INFORMATION AND SIGN WHERE INDICATED.
 
I understand the massage / bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I should immediately inform the therapist so the pressure and/or strokes may be adjusted to my level of comfort. Further, I understand that bruising can occur due to varying tissue and health conditions. I understand that bruising is more prevalent in longer/deeper therapies and certain areas of the body may also be more sensitive than others. I understand the goal is no bruising or discomfort and that communication is the key.  
I further understand that massage / bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and that I should consult a physician, chiropractor, or other qualified medical specialist for any mental, emotional or physical ailment that I am aware of. I understand massage/bodywork therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical, emotional or mental illness, and nothing said in the course of the session given should be construed as such. Because massage / bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known conditions and answered all questions honestly since some therapies could actually aggravate certain conditions. I agree to keep all therapists at the S.W.I.H.A. (Southwest Institute of Healing Arts) Student Clinic updated as to any changes in my medical profile and understand that there shall be no liability on the part of the therapist should I neglect to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. 
I understand that this is a school setting and files will be reviewed by students, staff and instructors for educational purposes only. 

Client Signature: _______________________________ Date: _________________
 
If under the age of 18 please have parent/guardian complete the following:
I hereby authorize ____________________________________________ permission to perform the following therapy on the minor child whose signature is above.          
(Please Circle)    Massage /  Energetic /  Asian /  Spa
 
_____________________________________________________________________________                        _____________________________________________________________________                      ____________________________________________
Parent/Guardian Signature	   	 Parent/Guardian Name (PRINT)	DATE

Body Specific Release Form
 
The purpose of this statement is to create clear boundaries between the Therapist and Client, and to educate the Client prior to any work done around the Breasts, Gluteals and Abdominals. Your comfort and safety are our highest concern.  

This release form is mandatory; otherwise, NO Pectoral, Gluteal, or Abdominal work will be exercised. Breast tissue is to be avoided when performing Pectoral massage.  However, it may require access or manipulation of the sides, or flanks of the upper body.   The Areola of the breast tissue will NOT be touched by the therapist and should NOT ever be exposed. 

By signing I have read and understand the above statement and consent to have area specific bodywork done by the therapist. 
 
Client Signature:_____________________________________   Date:__________________

Reasons for area specific bodywork: ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________