LISA KRONER
craniosacral therapy and massage for health and healing

Client Information Form

All clients must fill out and sign an intake/information form before their first session. At this time, the therapist will spend five to ten minutes assessing the client's needs and overall health, and check for any contraindications to massage. The safety, comfort, and health of our clients is always our top priority. A sample form is shown below.

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Massage and Bodywork Client Information

Name____________________________________    Date__________________
Address__________________________________    Phone_________________
________________________________________     Date of Birth___________

Occupation (optional) ________________________________

Emergency Contact - name and phone___________________

......................

Have you ever received professional massage?  

Date of last massage____________

What kind of pressure do you prefer?  light  medium   firm

What results do you want from today’s session?

Exercise activities_____________________________________________________

Stress level today?   low  medium  high

......................

Are you currently under the care of a health practitioner? 

If yes, please specify purpose/treatment:

List current medications:

List recent injuries/ accidents/ illnesses still affecting you:

List surgeries in past 3 years:

 Are you wearing contact, dentures, or any prosthetic devices?

Do you suffer from epilepsy or seizures?

Do you have any skin conditions?

Do you have any allergies to lotions or essential oils?

Do you have tension or soreness in a specific area?
If yes, please explain_______________________________________________________

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I have completed this form to the best of my knowledge and will inform the therapist of any change in my physical health, and change in my comfort level during my session.

I understand that the therapist cannot diagnose illness, disease, or any physical or emotional disorder, nor perform any spinal manipulations. I am responsible for consulting a physician for any physical ailments I have. I understand that the massage I receive is for the purpose of relaxation and relief of muscular tension and is non-sexual. Any sexual misconduct, verbal or physical, will result in immediate termination of the session and client will pay in full.

SIGNED _________________________________________DATE____________________

THERAPIST_______________________________________DATE____________________

 

 

Associated Bodywork & Massage Professionals
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