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
Pregnancy History
When is your expected due date?
When is your expected due date?
Pregnancy Conditions
Please check any that apply to you.
What amount of pressure do you prefer? *
What is your preference for music during a session? *
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 these questions in regards to the following family members. Family is different to each person. If possible, please tell about your relationship to your family of origin here: 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.
LIFESTYLE, EMOTIONAL & SPIRITUAL
If yes, please explain.
REPRODUCTIVE HEALTH HISTORY
When did your last menses begin? *
When did your last menses begin?
When was your last menses before becoming pregnant? If you are unsure of the exact date, pick an approximate one.
Reproductive Health History *
Check those that apply to you, including past and present.
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