Children and Teens - Therapeutic Massage Health History Form -

Client Name:*

First Last

Parent/Guardian’s Name:*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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.

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.

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.

Medication	Use