Soma Mark

Contact Mark Marcello--To Schedule Your Swedish Massage

Swedish Massage - One Hour Session price $60.00.  You will be called or emailed to set the date.  Please filled out the form below, so one does not have to be filled out when you come for your massage.

Name

Address

CityState

Zip Code  USA Other Canada

Email Address

What is the best time for us to talk?  (Click all that apply)

ASAP                    This week                    Next week

Mornings                Afternoons                    Evenings

Anytime                      Date

Home Phone Number:

Work Phone Number

Occupation:Cell Phone Number:

Date of BirthAge

Driver's License#

Client Information Consent and Evaluation Form:

Physician's Name:

Physician's Phone#

Person to contact in case of emergency, include name, relationship and Phone #:

Do you now, or have you had in the past:

1. History of heart problems, chest pain or stroke? yes no
2. Increased blood pressure? yes no
3. Any chronic illness or condition? no yes
4. Difficulty with physical exercise? no yes
5. Advise from physician not to exercise? no yes
6. Recent surgery (last 12 months)? no yes
7. Pregnancy (now or within last 3 months)? no yes
8. History of breathing or lung problems? no yes
9. Muscle, joint, or back disorder, or any previous injury still affecting you? no yes
10. Diabetes or thyroid condition? no yes
11. Cigarette smoking habit? no yes
12. Obesity (more than 20% over ideal body weight)? no yes
13. Increased blood cholesterol? no yes
14. History of heart problems in immediate family? no yes
15. Hernia? no yes
16. Allergies no yes
17. Dizziness no yes
18. Varicose veins no yes
19. Arthritis no yes
20. Headaches no yes
21. Low blood pressure no yes
22. Skin problems no yes please specify
23. Blood clots no yes
24. open lesions, cuts no yes
25. Spinal problems no yes

Any other conditions?

Please explain any yes answers:

Please indicate areas of complaint, pain, tension:

Date of onset of complaint:Pain Level minimal Moderate Severe

How is your complaint effecting your life?

What has been done medically?

Have you been hospitalized, if so, when, where, and why?

Are you currently or have you been under the care of a physician or other health care provider?

Any medical diagnosis No Yes Diagnosis name

Are you taking any medications of drugs?  What?

Past medical history, surgeries, broken bones, neurological? List all and describe these:

Any recent accidents/falls? Describe:

Have you been medically cleared? Yes No Does not apply to me

Do you have a medical condition that requires modification or is contraindicate for therapeutic massage and bodywork? No Yes Please describe:

Are you pregnant? No Yes if so, how many weeks

Stress/Anxiety level none minimal moderate severe

Do you wear contacts? no yes Have dentures? no yes

Orthotics no yes Prosthesis no yes

List the body area(s) which needs clinical attention:

Name body area(s) you don't want addressed during the session:

Comment or Questions:

INFORMED CONSENT

I, the undersigned, understand that massage therapy & bodywork is for the purpose of stress reduction, relief from musclular tension, general relaxation, and improvement of circulation.  I also understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorders; does not prescribe medical treatments or pharmaceutical; nor does he perform any spinal manipulations.  It has been made clear to me that professional massage therapy is not a substitute for medical treatment and that it is recommended that I see a physician for any physical ailment that I might have.  I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on changes in my physical health.  With this in mind, I agree that the massage therapist cannot be held liable for any problems that might arise as a result of my massage sessions.

Print name as Signature: 

Date: 

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