*The information herein does not replace medical advice

Similar documents
Recuperate Massage Intake Form

Client Intake Form - Therapeutic Massage

Client Intake Form. Phone:

Cardiovascular Consent Form

Massage Office Policies

Tranquility Massage Therapy & Reiki, LLC

CompassionMassage.com. Client Intake Form

MASSAGE I TAKE FORM RAQUEL CARTER LICE SED MASSAGE THERAPIST EXERCISE PHYSIOLOGIST REFLEXOLOGIST

Thank you. Terrie Yardley-Nohr Director of Programming

Client Intake Form Therapeutic Massage

Personal Information. Client Questionnaire. Basic Information. Date of Birth. Male Female Other Not Specified. Contact Information

Colorado Mesa University Campus Rec Services Massage Therapy Health History Questionnaire

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy

Thai Massage Health History Questionnaire

Module 8 Course Manual Christina Lyne

Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.

New Client Intake. First Name Last Name. Address. City State Zipcode Date of Birth. Home Phone Mobile Phone. Relationship to you Phone

ESSENTIAL ELEMENT Massage & Bodywork

City State Zip. Home Phone Mobile Phone. Can we text you appointment reminders? Yes / No If yes, who is your wireless carrier?

(emergency room pain)

Corner on Wellness Chiropractic Center Therapeutic Massage

Massage Client Intake Form

Dear Yoga Therapy Case Study Applicant,

Part 1. Massage 101. Watch these videos or take a course? Laurie Edge-Hughes, Copyright Laurie Edge- Hughes,

Goals/Outcome Have you had a professional massage before? Yes No If yes, how often do you receive massage therapy?

Home Address. City Postal Code Home Telephone # Business Telephone # Address. Emergency Contact Name, Address, Phone#

REFLEXOLOGY HEALTH RECORD

Shiatsu Intake Form PURCHASED PRODUCT/SERVICE. Date of Birth Age Height Weight. Home Address City State ZIP

Patient Health History Questionnaire

Patient Registration Form

BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage

Recovery and Wellness through Cryotherapy Egan Drive* Suite 191* Savage, MN 55378* *cryostrong.com. Physical Readiness Questionnaire

Keeping Accurate Records and Session Notes of your Clients

MISSOURI SPINE INSTITUTE John D. Spears, D.O.

Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form

HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC

PATIENT INTAKE FORM Health & Wellness

AHI - New Patient Information

NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE

Marga F. Massey, MD, FACS Getting to Know You! Patient Information Form

AUTHORIZATION TO RELEASE AND/OR OBTAIN PATIENT INFORMATION

Saleeby Chiropractic Centre, P.A.

Sincerely, Dr. Justin & Woodbury Spine Staff

KEY TO LIFE CHIROPRACTIC

Bon Vital Foot and Leg Massage for Frail Elders

Dynamic hip screw (sliding hip screw)

Best of Friends (Therapeutic Riding Program)

Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )

Essex Podiatry Associates Jeffrey N. Kaplan, DPM Neil E. Goldberg, DPM

Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me

th Street Urbandale, IA YOST

The Wellness Lounge Staff

Nursing Services Fall 2011

Name: (Last), (First), (Middle) Date of Birth: SS: Left or Right Handed: Complete Address: Phone: Home: Cell: Work:

Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B

Don Wheeler LMT. Joleen Kolk LMT Neuromuscular Therapy Corrective Massage Therapy

What is the most important information I should know about bortezomib? What should I discuss with my healthcare provider before receiving bortezomib?

Retinal Consultants of San Antonio PATIENT REGISTRATION

SEEDS OF HOPE FAMILY CHIROPRACTIC HEALTH HISTORY

Name: Date of Birth: Age: Address: City State Zip

Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone

HEALING HANDS CHIROPRACTIC, LLC 3 Hall Ave Wallingford, CT healinghandsdc.com

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

Highland Colony Dental- Donald K. Givan, DMD

NEW PATIENT INTAKE FORM

Laser Vein Center Thomas Wright MD Page 1 of 4

YWCA LOWER CAPE FEAR 2815 S College Rd Wilmington, NC (910)

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

REDDY & ASSOCIATES LLC D/B/A Reddy Medical Group D/B/A Reddy Urgent Care. Reddy Urgent Care Pre-Employment Physical Form

T R A C Therapeutic Riding At Centenary

RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118

Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?

Medical Information. (office use) MRN: CMRN: Last Name: First Name: Middle Initial: Date of birth: Age: Sex: M F Height: Weight:

PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE

Live Patient Response To Treatment: All symptoms disappeared after Myopractic posture balancing.

FINANCIAL POLICY STATEMENT

Personal Training Health Screening Questionnaire

1160 Suncast Ln El Dorado Hills, CA

Brisbin Family Chiropractic

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

Questionnaire for Lipedema Patients

Columbus Integrative Family Medicine Center Intake Form

Chapel Hill Pediatric Dentistry

Medical History Form

The benefits of THE EHM TECH Pendant

New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?

What do you believe is causing your most important health concern?

PATIENT INFORMATION NAME: LAST FIRST MIDDLE ADDRESS: CITY: STATE: ZIP CODE DOB: / / AGE: MARITAL STATUS: M S D W SEP

Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male

NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name

Surgical History Please list all operations and dates:

Overview. SKABT17 - SQA Unit Code HF Carry out massage using pre-blended aromatherapy oils

Lymphatic Drainage Massage Client History Form

New Patient Information & Consents

natural pain relief sprains cramps injuries tensions aches

National Occupational Standards

Patient Name: Date: Address City State Zip Code. H. Phone W. Phone Cell Phone

insurance information

Welcome to the Healthplex!

Transcription:

*The information herein does not replace medical advice Private Massage Consent Form Massage therapy for a child is not intended to replace other forms of healthcare. Used as a form of adjunctive healthcare, potential benefits for the child include: Skeletal: - Aids in supporting good posture and balance - Reduces muscle tension that could lead to potential medical problems - Increases nutrient flow to bones Muscular: - Relieves muscle tension and spasm - Aids in removal of lactic acid & carbonic acid - Increases the flow of blood and nutrients to muscles - Can increase or decrease muscle tone depending upon amount of pressure - Can reduce or increase joint mobility depending upon amount of pressure Digestive: - May relieve constipation - May relieve gas - Reduces water retention Cleans the blood by toning the kidneys Circulatory: - Stimulates blood and lymph circulation - Helps strengthen the immune system - Releases toxins held in the body Respiratory: - Improves breathing patterns - Helps reduce respiratory problems - Relieves tension in the chest allowing the lungs to expand more fully Nervous: - Relaxes and calms - Improves sleep patterns - Raises endorphin levels, promoting healing - Provides a safe and easy release from frustration and hyperactive behavior - The Vagus Nerve is stimulated influencing food absorption hormones (Insulin & Glycogen) Child s Name: Birthdate: Caregiver s Name : Address: City: State: Zip:

Phone: Cell/Pgr: Email: Referred By: In case of emergency. Name: Phone: My healthcare provider is: Phone: Contraindications for Pediatric Massage include: Fever/Temperature Acute infection, staph infection, illness or disease Skin disorder/condition which may be contagious or cause inflammation (fungus, rashes, herpes) Open sores, wounds or lesions Recent immunization/vaccination (wait 48 72 hours) Life threatening medical condition Unhealed umbilical cord (tummy massage contraindicated) Swollen lymph nodes Blood clots or a blood condition Diarrhea or other sickness Inflammation High Blood Pressure Hernia Osteoporosis Varicose Veins Broken Bones Deep Vein Thrombosis Pain Lability Thrombocytopenia Common Precautions for Pediatric Massage include: Apnea Bradycardia Tachycardia Abdominal Distention

Gastrointestinal or Jejunostomy feeding tubes Hydrocephalus Inflammations Edema Dysplasia Hemophilia Jaundice Recent Surgery HIV/AIDS Tumors Cancer Seizure Disorders Agitation Impulsivity Please indicate any of the high risk factors, complications that I should be aware of: Is there other relevant information about the pregnancy, child birth, about you or the child, that I should know? I,, understand that my child will be participating in pediatric massage therapy as a form of adjunct health care. I have noted above all complications, risks, or conditions my child has experienced AND I have obtained my child s healthcare providers release. I understand that my child will receive pediatric massage therapy as a form of adjunctive health care only and that it is not a substitute for other healthcare provided by a medical doctor or other licensed provider. I hereby release and hold harmless and defend the practitioner from any claims, liability, demands and causes of action from my and my child s participation in this therapy. Signature: Date: Print Name: Practitioner s Signature: Date: Print Name: Practitioner s Contact Information: Audrey Arbuckle, LMT, CPMT, CIMI Loving Hands On Wheels 317-519-6246 lovinghandsonwheels@gmail.com

Healthcare Provider Release for Pediatric Massage Therapy To: Child s Healthcare Provider(s) Re: Release for Pediatric Massage Therapy Your Patient s caregiver,, has requested pediatric massage therapy for your patient,. This therapy is to be provided by a certified practitioner (certification requires completion of a program of massage therapy or other professional healthcare certification, and an additional comprehensive hands on training program). It is our policy to provide pediatric massage therapy only if the child s healthcare provider has reviewed this request with the caregiver. In addition, if the child has any high risk considerations, has experienced any healthcare complications or has any contraindicated conditions, we require a written release from the child s healthcare provider stating any specific limitations or precautions that you feel to be appropriate. Please verify your clearance of this request by your signature below. This verification can be modified or withdrawn at any time should your patient s health status change. Thank you for your time and assistance. Child s healthcare status is: (please circle one) normal progression special considerations (detail below) Specific limitations or precautions: You may contact me directly for clarification or concerns regarding this patient. Yes / No Healthcare Provider Contact Information: Name: (please print) Phone: Signature: Date: Practitioner Contact Information: Audrey Arbuckle, LMT,CPMT, CIMI Loving Hands On Wheels 317-519-6246 lovinghandsonwheels@gmail.com

Healthcare Environment Medical Consent Form This consent form below would be used by a member of the healthcare team to obtain parental/caregiver consent after they have received physician consent. Documentation of Consent for Pediatric Massage Therapy I, (print name), spoke to the parent/guardian of (in person / on the phone) about Pediatric Massage Therapy. I informed them that this is treatment has been cleared by the child s physician. I discussed risks and benefits of massage. Benefits include relaxation, pain relief and comfort. Risks include allergy to massage oil/lotion(list type), emotional release related to relaxation, and musculoskeletal soreness. Opportunity was given for them to ask any questions and these questions were answered. Questions asked: The use of an interpreter was required? Yes No The parent/guardian stated understanding of this intervention and gave permission for Massage. Signatures Person obtaining consent: Interpreter: Date/time: Parent/guardian: Witness: Date/time:

Massage Therapist Treatment Note Pt name: MR# DOB Diagnosis: Date Time Session started: Time ended: Time spent with family/no massage given: Referral form checked for: () Allergies () Informed consent done () Assent obtained for patient 7yrs and older who is able to assent Hand washing done prior to treatment Personal protective equipment applied () Gloves () Mask () Gown () Other Permission of patient to touch today obtained () Verbal () Gesture () Tactile Duration of patient contact: Description of massage treatment: Position(s) Prone Held Supine Sidelying Sitting Present during session Parent Nurse Other family members Other: Patient Response: Concerns/Comments: Plan: Massage Therapist Name(print): Signature:

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback