Intake and Consent Form: Massage and Bodywork

What is your age?

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What is your occupation?

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Are you currently under the care of a physcian?

Yes

What is the reason for todays visit?

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What are you goals for todays session?

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What medications are you currently taking?

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List and prioritize your current symptoms/issues

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Are you currently pregnant ?

Yes

Do you have High or low Blood pressure? If so list which one

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Do you have a history of Heart disease, vericose veins , asthma, stroke, cancer, degenerative disorders, neurological disorders, HIV, Hepatitis or any contagious disease or condition?

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Do you have any known allergies?

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Is there anything about your health history you think I should be aware of?

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I consent to "before and after" photographs and videos for the purpose of documentation,potential advertising, and promotional purposes.

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By typing my full name I give Heather Trump permission to perform Massage and Bodywork services and hereby release her of any liabilities.

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