Client Information Date MM DD YYYY Name First Name Last Name Gender Occupation Referred by Email Mobile Phone Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth Physical Activities Medical History Spinal Injuries Broken Bones Pulled Muscles Sprains/Strains Low Back Pain Numbness/Tingling High Blood Pressure Low Blood Pressure Fainting Spells Headaches Asthma Skin Conditions Diabetes Arthritis Varicose Veins Osteoporosis Blood Clotting Issues Heart Disease Recent Surgery *Other *Other Medical Concerns Medical Providers Used (Physician, Chiropractor, Acupuncturist, Homeopath Medications Years Receiving Bodywork Styles of Work Problem Areas Massage Likes Massage Dislikes Statement of Understanding 1. Massage Therapy involves neither diagnosis nor treatment of any medical condition and is not a substitute for medical care. 2. Draping will be used at all times. 3. My genital area will not be exposed or massaged at any time. 4. My breasts will not be exposed or massaged unless I give written consent below. 5. I may itemize any areas of my body which I wish to be avoided and these will be avoided. 6. At any time I feel uncomfortable for any reason I may request that the session be ended and the session will be ended. *Areas you would like me to avoid Signature Breast Massage Consent In the State of Texas, massage of female breast tissue is permitted under the law only if the client gives explicit consent for the practice. If you wish to have your breasts undraped and massaged please indicate this below, then sign your name and enter the date. If you change your mind during your massage and no longer wish to give this consent, please ask the therapist to stop the practice and it will be stopped immediately. Yes, I would like to have breast massage included as part of my therapy No, I do not want breast massage included as part of my therapy Thank you!
