(813) 841-7767

Skincare Questionnaire Form

    Health Information

    Practitioner/Clinic Name:
    Contact Information:

    Client Contact Information

    Client Name:
    Date:
    Date of Birth:
    Gender:

    Address:

    Phone:
    Email:

    Referred by:

    Emergency contact:
    Phone:
    Physician/Health-care Provider name:
    Phone:

    Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)? NoYes
    Do you have a physician referral/prescription? NoYes
    Are you seeking insurance reimbursement?* NoYes

    *If yes, please complete the Billing Information form.

    Type of insurance coverage for this claim

    Massage Information

    Have you ever received professional massage/bodywork before? NoYes

    How recently?

    What types of massage/bodywork do you prefer?
    What kind of pressure do you prefer?
    What are your goals/expected outcomes for receiving massage/bodywork?

    How do you feel today?
    List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

    Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)? NoYes

    Explain:

    List the medications you currently take:

    Are you wearing contacts? NoYes
    Are you wearing dentures? NoYes
    Are you wearing a hairpiece? NoYes
    Are you pregnant? NoYes

    Health History

    Have you had any injuries or surgeries in the past that may influence today’s treatment?

    Circle any of the following health conditions that you currently have (If you are unsure, please ask):
    Blood clotsInfectionsCongestive heart failure Contagious diseasesPitted edema

    Please answer honestly, as massage may not be indicated for the above conditions.

    Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

    CurrentPast
    Muscle or joint pain
    CurrentPast
    Muscle or joint stiffness
    CurrentPast
    Numbness or tingling
    CurrentPast
    Swelling
    CurrentPast
    Bruise easily
    CurrentPast
    Sensitive to touch/pressure
    CurrentPast
    High/Low blood pressure
    CurrentPast
    Stroke, heart attack
    CurrentPast
    Varicose veins
    CurrentPast
    Shortness of breath, asthma
    CurrentPast
    Current Cancer
    CurrentPast
    Neurological (e.g. MS, Parkinson’s, chronic pain)
    CurrentPast
    Epilepsy, seizures
    CurrentPast
    Headaches, Migraines
    CurrentPast
    Dizziness, ringing in the ears
    CurrentPast
    Digestive conditions (e.g. Crohn’s, IBS)
    CurrentPast
    Gas, bloating, constipation
    CurrentPast
    Kidney disease, infection
    CurrentPast
    Arthritis (rheumatoid, osteoarthritis)
    CurrentPast
    Osteoporosis, degenerative spine/disk
    CurrentPast
    Scoliosis
    CurrentPast
    Broken bones
    CurrentPast
    Allergies
    CurrentPast
    Diabetes
    CurrentPast
    Endocrine/thyroid conditions
    CurrentPast
    Memory Loss, confusion, easily overwhelmed

    Comments:

    Consent for Treatment

    Name:
    Date:
    Parent or Guardian Signature (in case of a minor):
    Date: