Client Intake Form Body Restoration Massage Page 2                                                           Las Vegas Nevada                                                                  702 524 5686                                                  Please circle below any condition that you have had or do now have.                                                                                   *Please explain at bottom of page.                                                                                                                                                      HEALTH INFORMATION Pregnant or Recent Baby        Allergies        Gout            Arthritis            Bleeding Conditions           Cancer           Migraines                     Depression        Epilepsy        Herpes        Heart Conditions            Hepatitis          Kidney Conditions               Medication-Ports Chronic Infections        Stroke             Fibromyalgia               Tuberculosis                    High Blood Pressure/Low Blood Pressure Leukemia        Back Pain/ Surgery       Knee Pain/ Surgery         Open Wounds             Neck or Shoulder Pain/Surgery         Broken Bones Multiple Sclerosis        Eczema/Psoriasis        Herniated Discs      Abnormal Skin Condition             Numbness                   Fever Lack of or reduced feeling/sensation            Numbness             Joint Replacement/Surgery         Strains/Sprains         Diabetes                      Recent Injuries                       Paralysis                          TMJ Problems                Circulation Problems                  Contagious Conditions                                                          Is there an area of major concern that you want to improve?  List where. Is there anything that you feel I should know about you?                                                                                                        I understand that the massage/bodywork I will receive from Barbara Potter is provided for the basic purpose of relief from stress and muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that pressure or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be considered a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified health care specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of a session should be considered as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and have answered all questions honestly. I agree to keep the practitioner informed of any changes to the above profile and understand that there shall be no liability on the practitioner‘s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment for the full time scheduled. Client Signature  ___________________________________________________                                      Date   ______________________      Parent or Guardian Signature_________________________________________                                     Date   ______________________ Practitioner Signature  ______________________________________________                                      Date   _____________________                     Thank you for taking the time to complete this questionnaire.  This information is important for your overall assessment and will be kept in strict confidence. Explain any conditions listed above here: