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Medical History Form

Please fill out the following form
in order to participate in our activity.

Are you now under medical / therapeutic treatment?
Musculoskeletal:
Bone or joint; sprains/strains; soft tissue
Osteoporosis
Arthritis
Nervous:
Headaches; sleep disorders
Numbness/tingling/weakness
Cardiovascular:
Heart conditions
Varicose veins; blood clots
High / low blood pressure
Respiratory:
Breathing difficulties
Sinus problems; hay fever; asthma
Reactions:
Allergies; skin disorders
Digestive:
Constipation / bloating
Other:
Pregnancy
Cancer
Diabetes
Epilepsy
Lymphatic system
Medication:
Pain
Respiratory
Bloodthinners
Psychiatric
Antiinflammatories

I, (Client name) 

have chosen to consult with and hereby give consent for massage therapy to be provided by Mirko Perfetti who I understand is a member of the Association of Massage Therapists Ltd (AMT).

I have provided a detailed medical history. I do not expect the therapist to have foreseen any previous or pre- existing condition that I have not mentioned.

I understand that massage may provide benefits for certain conditions, but results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress- related conditions and provision of general wellbeing.

I also understand that massage therapy may produce side effects such as muscle soreness, mild bruising, increased awareness of areas of pain and light-headedness amongst other possible temporary outcomes.

I am aware that the therapist does not diagnose illnesses, prescribe medications nor physically manipulate the spine or its immediate articulations.

The therapist understands that I have the right to question procedures used and to receive an explanation of any procedures that the therapist performs.

 

I will tell the therapist about any discomfort I may experience during the therapy session and understand that the therapy will be adjusted accordingly.

Thanks for submitting!

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