Muscular Therapy Solutions of NH

 

Carl Bertolami, LMT

Muscular Therapy Practitioner

 

 

Confidential Treatment Intake Form

Print and complete this form prior to your first appointment.  This information is critical to your treatment as it may affect the manner in which your session is structured.  All information disclosed will be kept strictly confidential and will only be used for business pertaining to Muscular Therapy Solutions of NH.

 

Name:                                                                                                                            Date:

 

Home phone:                                                   Work Phone:                                Email:

 

Address:                                                                                          City/State/Zip:   

 

Occupation:                                                                                                       Date of Birth:

 

Employer

Reason for seeking treatment: (circle all that apply)  stress injury        soreness         relaxation         other

 

Please describe you exercise habits: 

 

Have you ever had therapeutic massage before?     Yes                    No                  

 

Do you wear contact lenses?      Yes              No                         Do you wear dentures?     Yes          No

 

Are you currently under a physicians care?                Yes         No          If yes, for what condition? 

 

Do you take medications for this condition?  Yes      No

 

List medications you do take: 

 

Do you take any sensation-altering drugs or medications?

(Pain medication, muscle relaxants, Alcohol or other depressants or stimulants)

If yes, please list:    

 

Allergies:

 

Please circle any of the following medical conditions/symptoms that you may have had in the past year.   These may affect technique choices.

 

Anemia                                               Diabetes                        Kidney Disease             Rheumatoid Arthritis

Angina                                                Disc problems                Liver Disease                Sciatica

Asthma                                               Fibromyalgia                  Lymphedema                Stroke

Atrial Fibrillation                                   Heart disease                 Migraines                     Skin Ulcer

Cancer                                                Hepatitis                        MRSA or MSSA            Stroke/TIA                          

Carpal Tunnel Syndrome                       Herpes Simplex              Multiple Sclerosis         Surgery

CHF                                                    Hospitalization                Osteoarthritis               Tendonitis                              

Contagious diseases                            Hypertension                   Phlebitis/Thrombosis    Varicose veins     

COPD/Emphysema                              Insomnia                         Pregnancy                   Whiplash

Dementia                                             Immune Disorders           Repetitive Strain Injuries                 

                                                                                                                                      

Other:

 

General Medical Signs and Symptoms-Please indicate if you currently have any of the following conditions

                                                       Yes                                 No                        Location: Please describe

 

Any areas of infection?
Any areas of swelling, edema or tendency to swell?
Any areas of numbness or abnormal sensation?
Any areas of pain or tenderness?

                                                                                             

 

Specific Medical Conditions

 

For your safety our therapists must be aware of all medical conditions for which you have been diagnosed.

Therapeutic massage may impact it and your health.

 

Condition:                                        Yes       No                                 Please describe

Arthritis
Cancer or Tumors
Cardiovascular Disease			Please circle all that apply:  Anemia, Angina, Arteriosclerosis, Congestive Heart Failure,  Heart Attack, Heart Murmur, Hemophilia, Hypertension/High Blood Pressure, Varicose or spider veins, Other
Diabetes
Injuries
Kidney or Liver disease
Respiratory or Lung conditions
Skin Conditions			Please circle all that apply: Acne, Abrasions/Cuts, Birthmarks/moles, Bruises, Dermatitis, Eczema, Herpes, Hives, Poison Ivy/Oak/Sumac, Psoriasis, Skin tags, Sunburns, Warts, Other
Other Medical Conditions not listed above

 

Please read and sign:

It is my choice to receive massage therapy.  I realize that the treatment is being given for the well-being of my body and mind.  This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow.  I agree to communicate with my practitioner any time I feel like my well being is being compromised.

I verify that all information provided is correct and current to the best of my knowledge.  I understand that any information provided by the therapist is for educational purposes only and is not prescriptive or diagnostic in nature. 

I have stated all medical conditions that I am aware of and will update my massage practitioner of any changes in my health status.  I understand that some medical conditions or symptoms may contraindicate massage therapy.  A referral from my primary care physician or other treating physician may be required before treatment.  I also understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment(s) and that I should see the proper qualified medical specialist for any mental or physical ailment(s).

I hereby give my consent to receive therapeutic massage by Carl S. Bertolami, LMT and will not hold this practitioner liable for any personal injury.

Thank You and Please enjoy!

 

Signature:                                                                                              Date: