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.
®
 Jane Ella Matthews, M.Ed,
  FeldenkraisĀ® Practitioner
  LMBT (Lic. # 1587)
 
jemtt@att.net
  864.918.9281

CLIENT INFORMATION FORM
Name (L)___________________________ (F)___________________ D.O.B.___/___/___
Address:_____________________________________________________
                 _____________________________________________________
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
     Method.
__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
    physician.
__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
__Cancer _________________________
__Blood Clots  __Vericose Veins
__Diabetes
__Osteoporosis
__Joint Replaced ________ Date ______
__Injuries _________________________
__Allergies ________________________
__Contagious Disease ______________

__Nervous System (brain, nerves, spine) _____________________________________
__Other Conditions _______________________________________________________
________________________________________________________________________

Medical History: Please check and explain any problem areas that apply to you.