Medical Assessment Form Personal InformationName(Required) First Last Phone Number:(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Male Female Other Emergency Contact Name(Required) First Last Emergency Contact Phone Number(Required)Medical HistoryDo you have any pre-existing medical conditions?(Required) Yes No Are you currently taking any medications?(Required) Yes No Do you have any allergies?(Required) Yes No Do you have any allergies to oils (essential oils, massage oils, and any other chemicals such as Mostorising cream, body cream, Ect)?(Required) Yes No If yes, specify allergens: Symptoms experienced (e.g., skin irritation, breathing difficulty, swelling):(Required) Have you undergone any surgeries or major medical treatments in the past?(Required) Yes No Do you have a history of the following?(Required) Arthritis Diabetes Heart Conditions High/Low Blood Pressure Respiratory Issues Neurological Disorders Bone or Joint Disorders Other Are you pregnant or planning to become pregnant?(Required) Yes No Have you had a professional massage before?(Required) Yes No List current medications & the conditions they are treating(Required) List any major accidents or surgeries (including dates)(Required) Current Health ConcernsWhat brings you in for treatment today?(Required) When did the issue or pain begin?(Required) What activities aggravate your condition?(Required) What activities alleviate your condition?(Required) Have you received any prior treatment for this issue?(Required) If yes, please specify(Required) Yes No Lifestyle InformationHow would you describe your daily activity level?(Required) Sedentary Lightly Active Moderately Active Very Active Do you engage in regular exercise?(Required) Yes No Do you have any occupational hazards (e.g., repetitive movements, heavy lifting)?(Required) Yes No Do you practice any stress management techniques (e.g., yoga, meditation)?(Required) Yes No Do you smoke or consume alcohol?(Required) Smoke Alcohol None Massage Selection Please select the massage experience you'd like to receive from the following listMassages for Physiotherapy Deep Tissue Massage Sports Massage Trigger Point Massage Lymphatic Drainage Massage Ice Massage Dry Cupping Massage Traditional Cupping Massage Breathing Massage Massages for Holistic Treatment Shiatsu Massage Thai Massage Reflexology Massage Indian Head Massage Traditional Cupping Massage Wet Cupping Massage Massages for Pure Relaxation Swedish Massage Aromatherapy Massage Hot Stone Massage Full Body Scrub Massage Indian Head Massage Goals and ExpectationsWhat outcomes are you hoping for from this session? Are there specific areas of focus for physiotherapy or holistic treatment? Short-term goals: Long-term goals: Consent(Required)It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I agree and would like to proceed with my treatment.Consent for Social Media ContentI hereby consent to video and/or photographic recordings being taken during my session at Breathe Treatments. I understand that these recordings may be used for educational, promotional, and social media purposes (e.g., Instagram, Facebook, website). I consent to full-body shots / focused shots only (circle one). I understand that no sensitive or identifying information will be shared without further consent. I agree to allow my content to be shared on social media.Name First Last EmailThis field is for validation purposes and should be left unchanged.
