Health Questionnaire Form

Health Information & Consent


Client Contact Information

Bodywork Information

Have you ever received profession Manual Lymph Drainage or massage before?

Health History

Please indicate conditions that you have or have had in the past:
Circle where you feel pain/discomfort:
Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that manual lymph drainage/massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical 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 the session given should be construed as such. Because manual lymph drainage/massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. Understanding all of this, I give my consent to receive care.

Thank you for taking the time to fill out this form.

CONTACT US TODAY

We look forward to hearing from you

Office Hours

Monday

8:00 am - 12:30 pm

2:30 pm - 5:30 pm

Tuesday

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2:30 pm - 5:30 pm

Wednesday

8:00 am - 12:30 pm

2:30 pm - 5:30 pm

Thursday

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2:30 pm - 5:30 pm

Friday

8:00 am - 12:30 pm

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Saturday

Closed

Closed

Sunday

Closed

Closed

Monday
8:00 am - 12:30 pm 2:30 pm - 5:30 pm
Tuesday
--------------- 2:30 pm - 5:30 pm
Wednesday
8:00 am - 12:30 pm 2:30 pm - 5:30 pm
Thursday
--------------- 2:30 pm - 5:30 pm
Friday
8:00 am - 12:30 pm ---------------
Saturday
Closed Closed
Sunday
Closed Closed

Location

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