Please read and initial.
__I understand that certain medical conditions contraindicate the use of massage and the use of some movements during a session. I have been sufficiently candid with the therapist in that regard.
__If such conditions exist, I have medical clearance to receive therapy.
CLIENT INFORMATION FORM
Name (L)___________________________ (F)___________________ D.O.B.___/___/___
Phone _______ _______ ____________ E-mail _______________________________
Emergency Contact / Rel:___________________________ Phone # _______________
Occupation / pastimes: ____________________________________________________
What are your concerns / goals? ____________________________________________
Referred by _____________________________________________________________
PLEASE READ AND RESPOND:
__ I have been given a description of Therapeutic Massage and the Feldenkrais
__I understand that neither Therapeutic Massage Therapy nor the Feldenkrais Method
are medical or chiropractic treatments. They do not diagnose or cure medical
conditions or subluxations, nor are they intended as a substitute for the care of a
__I understand that the Feldenkrais Method is primarily an educational approach. It
does not involve massage techniques and is not a form of Therapeutic Massage.
__I give the therapist permission to leave telephone messages regarding the
scheduling of sessions.
CLIENT SIGNATURE: _________________________________ DATE ______________
__Heart __Stroke (Date______________)
(__High __Low) Blood Pressure
__Blood Clots __Vericose Veins
__Joint Replaced ________ Date ______
__Contagious Disease ______________
__Nervous System (brain, nerves, spine) _____________________________________
__Other Conditions _______________________________________________________
Medical History: Please check and explain any problem areas that apply to you.
Jane Ella Matthews, M.Ed,
LMBT (Lic. # 1587)