Basic Contact Information
Today's Date *
Today's Date
Preferred Name *
Preferred Name
Legal Name *
Legal Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Best way to contact *
Emergency Contact *
Emergency Contact
Phone *
Phone
REASON FOR VISIT
Does it interfere with *
What amount of pressure do you prefer? *
What is your preference for music during a session? *
This will affect how deeply we massage your abdomen.
Medical History
Practitioner address
Practitioner address
Practitioner phone
Practitioner phone
General health conditions *
Check those that apply to you, including past and present conditions
Gastrointestinal history
What does your average breakfast, lunch and/or dinner look like?
How many 8-oz cups of water do you drink daily?
How many ounces of caffeine (coffee, tea, etc) do you drink daily?
Do you tend to eat more, less? Do you prioritize healthy meals?
What foods provide you comfort, pleasure, or you may attach guilt to eating?
Family of origin history
Please answer the following questions in regards to the following family members: Are they still alive? If not, what was the cause of death? Did they have any major health issues? In a few words, describe your personal relationship and feelings towards this person.
Describe your relationship to your parents.
Are they older / younger?
LIFESTYLE, EMOTIONAL & SPIRITUAL
If personally meaningful for you, describe how you culturally identify. How do you relate to your culture(s)?
If yes, please explain.
REPRODUCTIVE HEALTH HISTORY
When did your last menses begin?
When did your last menses begin?
If you are unsure of the exact date, pick an approximate one.
Reproductive Conditions
Check those that apply to you, including past and present.
History of traumas
The following questions are of a sensitive nature. Only answer what you feel comfortable answering. The pelvis and abdomen are especially vulnerable places that tend to store held emotions and also happen to be the least contacted parts of our bodies. Because of this, it is helpful for us to know your history with trauma so that we can create the safest and most respectful environment possible for you.
Pregnancy History
Include any pertinent details, eg vaginal birth, cesarean birth, etc.
Has any of your maternal lineage experienced infertility, fibroids, endometriosis, PMS or menopause?
Perimenopause, menopause and transitioning
Hormone-related conditions
HIPAA CONFIDENTIALITY & RELEASE
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 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 THIS MODALITY IS NOT A REPLACEMENT FOR MEDICAL CARE AND THAT THE PRACTITIONER DOES NOT DIAGNOSE MEDICAL ILLNESS, DISEASE OR OTHER PHYSICAL OR MENTAL CONDITIONS UNLESS SPECIFIED UNDER HIS/HER PROFESSIONAL SCOPE OF PRACTICE. AS SUCH, THE PRACTITIONER DOES NOT PRESCRIBE MEDICAL TREATMENT OF PHARMACEUTICALS, NOR DO THEY PERFORM SPINAL MANIPULATIONS. THE PRACTITIONER MAY RECOMMEND REFERRAL TO A QUALIFIED HEALTH CARE PROFESSIONAL FOR ANY PHYSICAL OR EMOTIONAL CONDITIONS I MAY HAVE. I HAVE STATED ALL MY KNOWN CONDITIONS AND TAKE IT UPON MYSELF TO KEEP THE THERAPIST/PRACTITIONER UPDATED ON MY HEALTH. CONFIDENTIALITY OF MEDICAL AND PERSONAL INFORMATION OBTAINED DURING THE COURSE OF THE PRACTITIONER’S WORK IS OF THE UTMOST IMPORTANCE. HIPAA REGULATIONS REQUIRE ALL PRACTITIONERS OBTAIN A SIGNED RELEASE FORM FROM THEIR CLIENT BEFORE TAKING ANY IN- FORMATION ABOUT THEM. THE BEST WAY TO BE FULLY COMPLIANT IS TO OBTAIN THIS RELEASE SIGNATURE AT THE INITIAL CONSULTATION. CLIENTS SHOULD RECEIVE A COPY OF THE FORM THEY SIGNED (UPON REQUEST), AND THE PRACTITIONER MAINTAINS A COPY FOR THEIR RECORDS I, (CLIENT), GIVE MY PERMISSION, FOR MY PRACTITIONER TO TAKE NOTES INCLUDING HEALTH HISTORY/MEDICAL AND/OR PERSONAL INFORMATION I CHOOSE TO DISCLOSE TO HIM/HER. I UNDERSTAND THIS INFORMATION MAY BE USED FOR THE PURPOSE OF PRACTITIONER CERTIFICATION AND/OR MAY BE SHARED WITH THE ARVIGO INSTITUTE, LLC FOR STATISTICAL DATA COLLECTION ONLY. ALL RELEVANT IDENTIFYING INFORMATION WILL NOT BE DISCLOSED, SUCH AS NAME, ADDRESS, SOCIAL SECURITY NUMBER, DATE OF BIRTH.
Client Signature * *
Client Signature *
By writing my name and date here, I sign that I agree to the above stated HIPAA Confidentiality and Release Agreement.
Date Signed * *
Date Signed *
PRACTITIONER SIGNATURE
JEEVAN SINGH, LMT 2017