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Children and Teens Health History Form
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Book Now
Manual Lymphatic Drainage
Post-Surgical Manual Lymphatic Drainage
Massage Therapy Benefits
Pricing
Therapists
Covid-19 Update and Information
Join Our Team
Intake Forms
Therapeutic Massage Intake Form
Manual Lymphatic Drainage Intake Form
Children and Teens Health History Form
Informed Consent Form Esign
MLD Videos For At Home Self Care
Clinic FAQs
Location
Children and Teens – Therapeutic Massage Health History Form
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Children and Teens – Therapeutic Massage Health History Form
Date of initial visit
*
Date Format: MM slash DD slash YYYY
Please Choose Therapist:
*
Carmela Wiese
Robin Wirsta
Morgan Brahmstadt
Client Name:
*
First
Last
Parent/Guardian’s Name:
*
First
Last
Phone (day)
*
Phone (evening)
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
*
Date of Birth
*
The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.
How would you rate your stress level on a scale of 1 (none) to 10 (very high)
*
1
2
3
4
5
6
7
8
9
10
Have you ever had a professional massage or other bodywork?
*
Yes
No
If yes, how often do you receive massage therapy?
Are you presently under a doctor’s, chiropractor’s or physical therapist’s care?
*
Yes
No
If so, for what?
Please list your current symptoms:
Please list any medications or supplements you take on a daily basis, and note what they are for.
Medication
Use
Do you have any allergies?
*
Yes
No
If yes, please explain
5. Are you wearing?
*
Contact lenses
Dentures
Hearing aid
None of the above
What kind of exercise do you do regularly?
*
What physical activities are common in your typical day?
*
How would you describe your general health?
*
What are you hoping to gain from massage?
*
Medical History
Please mark any of the following conditions which you currently have or have experienced in the past, indicating the dates at the right. Some may be contraindications for massage.
Systemic Infections:
Mononucleosis
Hepatitis
Other virus
If Other, Please Explain
Cardiovascular:
High Blood Pressure
Low Blood Pressure
Other
If Other, Please Explain
Musculoskeletal:
Whiplash
Low back pain
Strain/sprain
Broken Bones
Osteoporosis
Scoliosis
Foot Pain
Torn Ligaments/cartilage/tendons
Other
If Other, Please Explain
Neurological:
Headaches
Other
If Other, Please Explain
Urinary
UTI
Other
If Other, Please Explain
Endocrine:
Diabetes
Hypoglycemia
Other
If Other, Please Explain
Respiratory:
Hay Fever
Asthma
Other
If Other, Please Explain
Reproductive:
Menstrual cramps
PMS
Other
If Other, Please Explain
Digestive:
Constipation
Diarrhea
Other
If Other, Please Explain
Skin:
Eczema
Burns
Other
If Other, Please Explain
Surgery
*
Yes
No
If Yes, Please describe with dates:
Date of Visit
Reason
Cancer
*
Yes
No
If Yes, Please describe with dates:
Date of Visit
Reason
Please describe any other conditions (with dates)
Date of Visit
Reason
Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
It is my choice that my child receives massage therapy, a treatment being given for the well-being of body and mind. I agree to communicate with the practitioner if I ever feel my child’s well-being is being compromised. I understand that massage practitioners do not diagnose illness, disease or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have stated all of my child’s medical conditions that I am aware of and will update the massage practitioner on any changes in health status. I understand that massage sessions are strictly therapeutic; inappropriate behavior will result in termination of the session. I have read the Therapeutic Massage Center of Middleton’s intake questions and understand them.