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Personal Information

By Scott Simmons,2014-05-12 18:22
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Personal Information

    Gateway Therapeutic Massage

    118 N. Liberty St. Ste. A Port Angeles WA 98362

    (360) 457-7379

    Name _______________________________ Today’s Date________________ Address ______________________________State ________ Zip __________ Hm Phone_______________Wk Phone ___________Cell Phone____________ D.O.B._____________ Email for Newsletter ___________________________ Emergency Contact _______________________Number__________________

    Primary Care_____________________________Number_________________

    Have you received a professional massage before? Yes No When__________ How often do you receive massage? ____________________________________ What is your reason for massage today? _________________________________ Please list the areas on your body that need extra attention today? ____________

    ________________________________________________________________

    Are you using any other types of therapy? (Chiropractor, Acupuncture, Physical

    Therapy) ________________________________________________________ I f there is pain, are things gradually getting better or are they getting worse? Better Worse Explain __________________________________________

    Frequency of Pain: (circle a number from the scale below)

    None Sometimes All the time

     1 2 3 4 5

    Severity of pain: Mild__________ Moderate ___________ Severe __________ Have you had a doctor look at this concern? (If yes, what was his/her diagnosis)

    ________________________________________________________________

    What did the doctor recommend? ______________________________________ Anything you did not like about your last massage? ________________________

    ________________________________________________________________

    Please list any areas on your body that you are really ticklish or prefer not to be

    massaged? ________________________________________________________

Have you ever received a professional facial or skin care treatment? Yes No

    When? ___________________________ How often? ______________________ Would you say you have skin that is Normal Dry Oily Combo

    What skin care products are you using now? _____________________________ __________________________________________________________________

    Are you taking Retina A or Accutane? _______________________________ Do you have any skin allergies? ___________________________________

Please describe your current stress level. Low Moderate High

    List any hobbies or activities that reduce your stress. _____________________ __________________________________________________________________

    How often do you perform these activities?______________________________

    Seizures/Convulsions __ Pain with movement __ Contact lenses

    __ Numbness/Tingling __ Asthma __ Cold hands

    __ Sciatica __ Allergic reaction __ Sinus Allergies

    __ High blood pressure __ Skin cond/rash __ Pregnant __#of mo.

    __ Low blood pressure __ Infectious Cond. __ Nausea

    __ Osteoporosis __ Inflammation __ Gas

    __ Fainting __ TMJD __ Constipation

    __ Varicose veins __ Headaches __ Diarrhea

    __ Bruise easily __ Loss of memory __ Abdominal

    __ Heart cond. __ Loss of balance __ Low back pain

    __ Bursitis __ Ringing in ears __ Neck pain

    __ Arthritis __ Leg cramps __ Shoulder pain

    __ Chest pain __ Cold feet __ Dentures

    __ Shortness of breath __ Swollen ankles __ Hearing aids

    __ Diabetes __ Anemic __ Cancer

    __ Insomnia __ Hepatitis __ HIV

    __ Artificial Joint __ Stroke __ Thyroid cond.

    __ Other ____________________________________________________________

    General History: Please list dates and events of any and all of the below, with in the last 10 years?

    Car Accidents:__________________________________________________________ ________________________________________________________________________

    ________________________________________________________________________

    Injuries: ________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    Surgeries: ______________________________________________________________ ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

    Major Illnesses: __________________________________________________________ ________________________________________________________________________

    ________________________________________________________________________

    Medications: ____________________________________________________________ ________________________________________________________________________

    ________________________________________________________________________

    ________________________________________________________________________

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