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Home
Yuen Method
Remote Sessions – Your Team
Workplace Energy
Teleclinics
Therapeutic Massage
About Us
Buy Sessions
Contact
Testimonials
Patricia Bigler In Person Massage Form
Prior to your appointment - Please fill out this form and email to back me by clicking the Send button below.
Date
MM slash DD slash YYYY
Name
First
Last
Address
Street Address
City
Email
Cell Phone
Home Phone
Date of Birth
Are you presently taking any medication?
Yes
No
If yes, please list and explain.
Have you had a recent major surgical procedure or injury?
Yes
No
If yes, please explain.
Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?
Yes
No
If yes, please explain.
Please check your stress level:
1 - Low
2 - Medium Low
3 - Medium
4 - Medium High
5 - High
Please check your pain level:
1 - Low
2 - Medium Low
3 - Medium
4 - Medium High
5 - High
Are you allergic to any Lotions or Oils?
Yes
No
Which ones?
Check the following conditions that apply to you, past and present. Please add your comments to clarify the condition.
Musculor-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
Tendonitis
Bursitis
Arthritis
Osteoporosis
Scoliosis
Other
Nervous System
Numbess/tingling
Fatigue
Sleep disorders
Ulcers
Paralysis
Herpes/shingles
Cerebral Palsy
Epilepsy
Chronic Fatigue Syndrome
Multiple Sclerosis
Muscular Dystrophy
Parkinson's Disease
Other
Circulator/Respiratory
Dizziness
Shortness of breath
Fainting
Cold feet or hands
Cold sweats
Stroke
Heart condition
Allergies
Asthma
High blood pressure
Low blood pressure
Other
Digestive
Indigestion
Constipation
Intestinal gas/bloating
Diarrhea
Irritable bowel syndrome
Crohn's Disease
Colitis
Other
Skin
Rashes
Allergies
Athlete's foot
Acne
Impetigo
Hemophelia
Other
Loss of Appetite
Depression
Difficulty concentrating
Hearing Impaired
Visually Impaired
Diabetes
Fibromyalgia
Post/Polio Syndrome
Cancer
Tuberculosis
Other
Trauma
Falls
Accidents
Other
Reproductive System
Pregnancy
Other
Please clarify any conditions you have checked above:
I understand that a massage/energy Therapist does not diagnose disease, illness, or prescribe any treatment or drugs, nor do they provide spinal manipulation. I understand that draping will be used at all times. I understand that if I become uncomfortable for any reason that I may ask the Therapist to end the massage session, and they will end the session. I understand that the massage/energy Therapist may end the session for any inappropriate behavior. I have stated all of the conditions that I am aware of, and this information is true and accurate. I will inform the health care provider of any changes in my status.
I agree to the terms and conditions as stated above.
*
Yes
By typing your name below constitutes a signature.
Name
First
Last
Date
MM slash DD slash YYYY
