Homephone: Cell Phone

Homephone: Cell Phone

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Client Form

Name: Date:

Address:

HomePhone: Cell phone:

E-Mail:

Date ofBirth: Age:

Marital Status:

Referredby:

Occupation:

Physician: Phone:

InEmergencyNotify: Phone:

Client Assessment Form

Anaccurate healthhistoryisimportanttoensurethatitissafeforyoutoreceivetreatment. Ifyour healthstatuschangesinthefuture,pleaseletusknow. Allinformationgatheredfor treatmentsis confidential. Youwill beaskedtoprovidewrittenauthorizationforrelease ofanyinformation.

Cancelation Policy Please note that a 24 hours advance notice is required for cancellation of all appointments; otherwise you will be charged $50.00 for the missed visit.

Please note that a 24 hours advance notice is required for cancellation of all appointments; otherwise you will be charged $50.00 for the missed visit.

Are you currently taking any medications?(Y/N)

Name of Medication / Reasonfor taking / Forhowlong
Med1
Med2
Med3

Past Injury or Surgeries, Painful or sensitive scars:

Describe / When / Locationofsensitivescars
Injury/Surgery
Injury/Surgery
Injury/Surgery

Body Map

Where in the body are you experiencing symptoms or pain?

  • Head
  • Neck
  • Chest
  • Upper Back
  • Lower Back
  • Shoulder
  • Muscles
  • Arms
  • Hands
  • Abdomen
  • Urinary
  • Genitals
  • Skin
  • Hip
  • Knee
  • Legs
  • Foot
  • Ankle

Please describe your main concerns:

______Please mark areas of Pain (X), Discomfort (D) or tension (T)

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Health History

Check the appropriate box if you have or have had recent problems with any of the following:

Major Conditions

  • Arthritis
  • Bursitis
  • Headaches
  • Swollen Joints
  • Fibromyalgia
  • High Blood Pressure
  • Low Blood Pressure
  • Poor Circulation
  • Anemia
  • Stroke
  • Seizures / Convulsions
  • Heart Conditions
  • Constipation
  • Sinus / Allergies
  • Hematomas
  • Phlebitis
  • Varicose Veins
  • Cancer
  • Skin Conditions
  • Pregnant? ____# of months
  • Menstrual Pain
  • Warts
  • Athlete’s Feet

Skin and Hair

  • Rashes
/
  • Ulcerations
/
  • Hives/AllergicDermatitis
/
  • FaceFlushing

  • LossofHair
/
  • Itchyskin
/
  • Eczema/Psoriasis
/
  • Weak orridgednails

  • SkinDiscoloration
/
  • Acne
/
  • ChangeinSkin/Hair Texture
/
  • Fungal Infection

Throat, Nose Ears, Eyes, Head

  • Dizziness
/
  • Difficultyswallowing
/
  • Eye pain
/
  • Headaches

  • SinusInfection
/
  • Recurrentsorethroat/Colds
/
  • Jawclicks/locks
/
  • Migraines

  • Earaches
/
  • Spotsinfrontofeyes
/
  • BlurredVision
/
  • NightBlindness

  • Ringing inears
/
  • Sores onlips/tongue
/
  • Cataracts
/
  • Facial pain

  • Poorhearing
/
  • Dental problems
/
  • Grinding Teeth
/
  • TMJ

Respiratory

  • Coughing Blood
  • Cough/ Wheezing
  • Pneumonia
  • Asthma
  • Pain with deep inhalation
  • Emphysema
  • Bronchitis
  • Chronic Cough

Cardiovascular and Circulation

  • Chestpainorpressure
  • IrregularHeartbeat
  • Palpitations
  • Easytofaint
  • Coldhands/Feet
  • Swelling ofhands/feet
  • BloodClotting problem
  • VeinInflammation
  • Shortness ofbreath
  • Varicose/Spiderveins
  • Pressureinchest
  • Anemia
  • Low bloodpressure
  • Spontaneoussweating
  • Dizziness
  • Reynaud’sDisease
  • Highbloodpressure
  • ElevatedBloodCholesterol
  • Coldhandsandfeet
  • Stroke
  • Heart Condition – please explain ______

Digestion/Gastrointestinal

  • Nausea
/
  • Vomiting
/
  • ChronicDiarrhea
/
  • Constipation

  • Gas
/
  • Guminflammation
/
  • Ulcer
/
  • Bloodinstool

  • Indigestion
/
  • Badbreath
/
  • Toothimplants
/
  • Hemorrhoids

  • Bleeding
/
  • Hernia
/
  • Loosestools
/
  • Abdominal crampspain/cramps

  • Bloating
/
  • Acidreflux/GERD
/
  • Excessiveappetite
/
  • Poorappetite

  • Significantthirst
/
  • IBS/Crohn’s
/
  • Food allergy/toleranceaallergies/intolerance

Genito-Urinary

  • Genital Herpes
/
  • Kidney stones
/
  • Urinary tract infection
/
  • Urgent urination

  • Infections
/
  • Sores on genitalsinflammation
/
  • Pain in urination

  • Impotence
/
  • Pain in testicles
/
  • Unable to hold urine

  • Prostatitis
/
  • Decreased libido
/
  • Premature ejaculation

  • Excessive libido
/
  • Blood in urinereflux/GERD
/
  • Burning urination

  • Night urination
/
  • Scanty flow
/
  • Dribbling after urinationaallergies/intolerance

Reproductive

  • Difficult/PainfulIntercourse
  • OvarianCysts
  • Age of first menstruation:
  • Last menstruation
  • Vaginal discharge
  • Endometriosis
  • UterineFibroids
  • Date oflastPAP/Pelvic
  • Irregularmenstruation
  • Fibrocysticbreasttissue
  • Pregnancies (Howmany)
  • Painful menstruation
  • PolycysticOvarianDisease
  • Caesareanbirths (Howmany)
  • Infertility
  • Abortions (When)

  • PMS
  • Abnormal Pregnancies(Reason):

Do you practice birth control?

  • No
  • Yes What type? ______Since when? ______

Neurological/Psychological

  • Seizures
  • LossofBalance
  • Vertigo/Dizziness
  • Areas ofnumbness
  • Lackof coordination
  • Poormemory
  • Concussion
  • Vivid dreams
  • Easilysusceptibletostress
  • Anxiety/PanicAttacks
  • BadTemper/Irritability
  • Depression
  • Waking up at night
  • Seasonal Affective Disorder
  • Nervousness
  • ADD/ADHD
  • Bi-PolarDisorder
  • PoorSleep

Have you ever been treated for emotional problems?  Yes  No

Have you ever considered or attempted suicide?  Yes No

Have you ever been treated for substance abuse?  Yes No

Health History Declaration

ForYourInformation

Anaccurate healthhistoryisimportanttoensurethatitissafeforyoutoreceivetreatment,ifyourhealthstatus changesinthe future please besuretoletus know.

Thisformmustbeupdatedannually.

Allinformationgatheredinthisform iskeptconfidential andwillnotbereleasedunlesstheclientissuesawritten consent,allowingthe practitionertoreleasetheinformation.

IherebydeclarethattheinformationthatIhavegivenaboveregardingmyhealth condition isaccurateandtrueto thebestof myknowledge.

Name: ______Signature: ______Date: ______

(Please print)

Informed Consent to Treatment

Prior to any massage or sound healing your choice of an Infrared Sauna orSoftub hot tub is included. Althoughthe utmostcarewill betaken toensuresafetyandcomfortforourclients/patients,intheeventofinjuryatEnchanted Healing Center, Colleen Linseman or Wynne Ross or Enchanted Healing Center will notbe heldliableforanyreason.

Please beawarethatwhenusing thefollowingtreatmentmodalities:ShiatsuTherapy, Deep Tissue Massage, Swedish Massage, Reflexology Massage, Aromatherapy Massage, Sound Healings or Pedicure/Manicure, it can be that somevery rarereactionsmay occur and may include bruising(hematoma),fainting,dizziness,nausea,pneumothorax,riskofinfection.

Each session may intuitively include chakra purification smudging with gifted sacred eagle feathers. Healing herbs such as palosanto, agua de florida spirit water from Peru, copal, sweetgrass, sage, aromatherapy oils, crystal Amega wand and tonal, tribal vibrational sounds, drumming, chanting, are some of the elements Colleen may be called to use during your healing session.If at any time you are uncomfortable with the technique being used, you cantell Colleen and you can also stop the treatment at any time.

Massage therapy involves the manipulation of the soft tissues of the body, skin, muscle, ligaments and connective tissues, usingtechniques to produce therapeutic and healing results.With massage therapy, the client disrobes to their comfort level, and lies on a table between two sheets. Only the areas of the bodybeing directly treated are uncovered at one time. If at any time you are uncomfortable with the pressure or technique being used, you cantell Colleen (i.e. todecrease or increase pressure, irritating, etc.).

Pleasebeawarethatyoumayrequesttostoporalterthetreatmentatanytimeandforanyreasonandthetherapist willcomplywith yourwishes.

I have read the above and give consent for treatment.

Name: ______Signature: ______Date: ______

(Please print)

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