Client Information Form Step 1 of 8 12% Welcome to Healing Journeys! I always ask for general information and a health history in advance of your first session. Please be as thorough as possible - this helps me plan the safest and most effective sessions for you. I do allow extra time in the first session for discussion and questions - without cutting into your time on the table.About YouName(Required) First Last Marital Status Single Married In a relationship Separated Divorced Widowed Date of Birth(Required) MM slash DD slash YYYY What best describes your gender?(Required)FemaleMaleNon-binaryOther / Not listedUnsurePrefer not to sayPronounsAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone(Required)Home PhoneEmail(Required) OccupationEmergency ContactRelationshipEmergency Contact PhoneHow did you hear about me? Doctor referral Friend referral Google Social Media Yelp Other Got spots that need extra focus/TLC?Use this space to tell me where you’d like focus during your session—or if there’s anything I should be aware of. We’ll go over your medical history a bit later in the form, so no need to get super detailed here.Are there specific areas you would like me to AVOID during your session?Have you had professional massage, reflexology, or lymphatic drainage before? Yes No If yes, how long ago?Are you wearing any of the following for your appointment (check any that apply): Contact Lenses Dentures Hearing Aid(s) Lashes / Lash extensions Wig / Hairpiece Do you generally sit for long hours at a workstation, computer, or driving? Yes No Your Health HistoryPlease check the box below if any of the following are true: Have had a fever within the last 24 hours Recently experienced respiratory/flu-like symptoms (i.e. cough, congestion, sneezing, etc), sore throat, or shortness of breath Recently experienced GI issues, such as nausea, diarrhea, or vomiting Contact, within the last 14 days, with anyone diagnosed with COVID or related symptoms (including within your household) Have received a vaccine within the last 72 hours Have traveled internationally within the past week Covid-19 Checkbox - YES YES, any of the above items apply to me Do you have any allergies or sensitivities?This is especially important to know as we may occasionally have aromatherapy and other scents in the office. I will do my best to keep you safe from an allergen or sensitivity that you notify me about. Do you have difficulty lying flat on your back, side or stomach?Do you experience significant stress in work, home or other aspect of your life?Please tell me what you're comfortable relating, and how this has affected your health.Please indicate if any of the conditions apply to you:(Required) Allergy / Sensitivity (food or other) Anxiety Arthritis (Osteo or Rheumatoid) Artificial Joint / hardware Asthma or other chronic respiratory condition Autoimmune Disorder Back / Neck problems Blood Clots / DVT Cold / Flu / COVID Decreased Sensation / Numbness Depression Diabetes Easy Bruising / Bleeding Ehlers-Danlos Syndrome Epilepsy / Seizures Fever (currently or within the past 24 hours) Fibromyalgia Headaches / Migraines Heart condition High or Low Blood Pressure Insomnia / Sleep disorder Lyme disease Lymphedema (diagnosed) Open Sores / Wounds Osteoporosis / Osteopenia Perimenopause / Menopause Pregnancy Recent injury or surgery Reproductive health condition or disorder Sensitivity to heat/cold Skin condition(s) - especially anything contagious Stress TMJ / Jaw pain Trauma Varicose Veins Vertigo Other - not listed None of these Please provide details on any of the conditions noted above:NOTE: If you are seeing me for Oncology Massage or Lymphedema care, we will cover cancer and lymphedema in detail in a later section of this form.Have you ever had any lymph nodes removed or radiated?(Required) Yes No Please list any prescription or over-the-counter medications you are currently taking:(Required)Do you have a history of cancer, or are currently in treatment for cancer?(Required) Yes No Your Cancer JourneyWhen were you first diagnosed with cancer?What type of cancer, and where was/is it located?Is cancer currently active? Yes No Are you being treated now? If no, what was the date of your last treatment?Did your treatment include any removal or radiation of lymph nodes?Did your treatment include radiation therapy?What treatments have you undergone, and when? Please list dates and types of surgery and other treatments.Please list any current medications, including chemotherapies (past and present chemos if possible), as well as the reason for the medication.Any other medical treatments? Example: physical therapy, etc. Please be sure to include dates where possible.Do you have any SITES that I should be mindful of due to: Area of infection Blood Clots (history or risk) Bone or spine metastasis Fracture history Incision / wound / drains / dressings IV / port / Ostomy / Catheter / Other Device Neuropathy Radiation site Skin sensitivity / condition Tumor site Other Please give details for any SITE concerns noted:Do you have any PRESSURE restrictions due to: Anticoagulants Area of pain or burning Bone or spine metastasis Fatigue Fragile bones Fragile / sensitive skin Fragile veins Infection or fever Low platelet count Lymphedema (history or risk) Nausea Pain medication Recent surgery Steroid meds Other Please give details for any PRESSURE concerns noted:Do you have any POSITIONING needs due to: Difficulty breathing Discomfort Incision Medical device(s) Medication Ostomy Swelling Tender skin Tumor site(s) Other Please give details for any POSITIONING concerns noted:Has cancer or cancer treatment affected any of the following functions in your body? Lungs Liver Nervous System Heart Kidney Blood Counts Energy Level Other Please provide additional details on any / all of the list items noted:Do you have any of these general signs/symptoms? Any swelling, or tendency to swell? Any pain or tenderness? Any numbness or reduced sensation? Any areas that are warm or red? (inflammation) Fatigue? Other Please provide additional details on any / all of the list items noted:Describe your activity level - what activities are you able to participate in?Be sure to include information about work, exercise, interests or hobbies.Please select the areas that you would like to receive massage to: Abdomen Arms Back Buttocks / Gluteals Chest Face Feet Hands Head / Scalp Legs Neck Shoulders My doctor is aware that I am receiving massage: Yes No Will we be addressing lymphedema or chronic swelling with lymphatic therapies in your scheduled session?(Required) Yes No Maybe? (It's absolutely okay to not be sure how to answer this) Lymphedema & Chronic SwellingHave you been formally diagnosed with lymphedema? Yes No If you have been diagnosed with Lymphedema, by whom were you diagnosed?Was there a triggering event which caused the swelling/lymphedema?Please describe briefly how and why your lymphedema developed.Please describe your swelling/lymphedema, including where it is and its severity:Do you have pain?Have you had any infections (cellulitis)? If yes, how long ago was the last one?Do you have any loss of function or mobility?Do you have any difficulties with any of the following? Walking Dressing Reaching feet and toes Bathing/showering Preparing Meals Other Have you had any previous treatment for swelling/lymphedema? Manual Lymph Drainage (MLD) Compression bandaging Compression garments Compression pump Flexitouch Low Level Laser Lymphedema Exercise Other Please tell me about your experience, success or lack of success with these treatments:Do you currently wear a compression sleeve or stocking?If yes, how often do you wear it and how old is it?Do you currently use compression at night?If yes, please provide detailsDo you exercise regularly?If yes, please give some additional detailsDo you have any goals in mind for your sessions with me? Is there anything else about your health history that you think would be useful for me to know? Waiver and Consent for TreatmentConsent(Required)Please take a moment to read the following: I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow. If I experience pain or discomfort during sessions, I will immediately inform the massage therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session. I understand that the services offered today are not a substitute for medical care. I understand that my massage therapist is not qualified to perform spinal or skeletal adjustments, prescribe, or diagnose physical or mental illness. I affirm that I have notified my massage therapist of all known medical conditions and injuries. I agree to inform the massage therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so. I understand that any sexual misconduct or other harassment will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. If for any reason I am uncomfortable, I may ask the therapist to cease the massage and the therapist will end the session. By signing this release, I hereby waive and release my massage therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. Understanding all of this, I give my consent to receive care.(Required)Please type your full name as your digital signature:(Required)Date completed / submitted:(Required) MM slash DD slash YYYY Δ
