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Therapeutic Touch Of Ponte Vedra, INC
Terri Bishop-Brahen, RN,LMT,LLCC
FL License #MA22716 MM8630

 Name:__________________________________  Date:___________________________________
 Address:________________________________  City:____________________________________
 State:__________________________________  Zip:_____________________________________
 Home Phone:_____________________________  Work Phone:______________________________
 Occupation:______________________________  Cell:_______________________Text ok? Yes No
 Email:___________________________________  Referred by:______________________________
 Date of Birth :____________________________  Age:____________________________________
 Partner's Name:___________________________  Partner's Occupation:______________________
 Emergency Contact & Phone#______________________________________________________________

 Circle any symptoms you have presently or in the past:

 Abdominal Problems  Eczema  Immune Disorder  Poor Circulation
 Adult Acne  Emphysema  Insomnia  Sciatic Pain
 Allergies  Epilepsy  Leg Pain  Shoulder Pain
 Anemia  Fatigue  Back Pain  Sinus
 Anger/Resentment  Epstein-Barr  Multiple Selerosis  Skin Problem
 Arthritis  Foot Problem  Neck Pain  Stoke
 Asthma  Goiter  Nervous/Depression  Thyroid Problem
 Cancer  Headaches  Numbness  Tennis/Golf Elbow
 Carpal Tunnel  Herpes Simplex  Pneumonia  Tuberculosis
 Cold Sores  High / Low BP  Inflammatory Disorder  Ulcers
 Constipation  H.I.V/AIDS  Physical Trauma  Venereal Disease
 Diabetes  Hernias  Hand Problems  Varicose Veins
 Dizziness  Indigestion  Circulation Problems  Lymphatic problems

 List any illnesses not listed above:

 List any surgeries and dates:


 Are you pregnant? YES / NO

 List Breasts Symptoms:

 List Menstrual or Menopausal Symptoms:

 Are you presently under the care of a medical, chiropractic, or mental health practitioner? Yes / No
 Name of healthcare providers:


List prescription/nonprescription drugs you take:


 List vitamin, mineral, herbal preparations:


 Have experienced Therapeutic massage, Energy work, Lymphatic, or Reflexology before? Yes / No

 Where?  When?

 What are your main area(s) of Discomfort?

 How long have you had this condition?

 List any previous diagnostic tests and treatments you have received for this condition:


 Do you wear a hair piece or wig? Yes / No


 Do you wear contact lenses? Yes / No

 Habits  Heavy  Moderate  Light  None
 How do you rate your general health  Excellent  Good  Fair  Poor

 What are your goals for your sessions?

 What type of therapy are you interested in today?

I understand that massage therapy is not intended to be a substitute for proper medical care.
My therapist has not expressed or implied that massage is the primary treatment for any specific illness or disease. I understand that massage is adjunctive therapy that can be coordinated with advice, treatment, or prescriptions recommended by my regular physician. The decision to follow or reject a series of therapies is left to my own discretion. I am advised to remove clothing to my comfort level only. With certain therapeutic modalities, clothing may remain on. If at any time during the massage I feel uncomfortable with any aspect of it I will request the treatment be discontinued. As well, the therapist has the right to discontinue a session should it be deemed appropriate to do so.
I hereby agree that I have given correct, complete, and honest information listed on this health questionnaire form.                
The cancellation policy of this practice is at least 24 hours notice. I understand that I am liable for the full fee for the session should I cancel short of the 24 hour time frame.

 ______________________________________________ __________________________________
 Client signature Date

 Therapist's notations: