To schedule your appointment, please text or call 775-848-5450.

Debra Rilea, NSBMT #1501

1005 Terminal Way, Ste. 170

Reno, Nevada 89502

CLIENT FORM

Name:  ____________________________________________________________________________

Address:  ___________________________________________________________________________

City, State, Zipcode: __________________________________________________________________

Best number to reach you:____________________________       OK to text cell phone?  Yes ☐   No ☐

Email:_____________________________________________      OK to email?  Yes ☐   No ☐                                                      

Date of Birth:___________________________ Occupation: ___________________________________            

Referred By: ___________________________  May I send them a thank you?    Yes ☐   No ☐

Massage/Health Information

Have you ever received professional massage/bodywork before?   Yes ☐   No ☐

How recently? ___________________________________

What types of massage/bodywork do you prefer? ___________________________________________________

What kind of pressure do you prefer?   Light ☐    Medium ☐     Firm ☐

What are your goals/expected outcomes for receiving massage/bodywork?______________________________

­­­­­­­­­­­­­­­­­­­­___________________________________________________________________________________________

___________________________________________________________________________________________

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)?   Yes ☐   No ☐

If yes, please explain: ____________________________________________________________________________________ ____________________________________________________________________________________

List the medications you currently take: ______________________________________________________________________________________________________________________________________________________________________________________

Are you wearing contacts?   Yes ☐  No ☐              Are you wearing dentures?   Yes ☐  No ☐                   

Women only, are you pregnant?   Yes ☐  No ☐

                                                                                                                                    Continued back page

Health Information

Have you had any injuries, illnesses or surgeries in the past that may influence today’s session:

____________________________________________________________________________________

Circle if you have any of the following health conditions, massage may not be indicated for these conditions:

blood clots        infections        congestive heart failure        contagious diseases        pitted edema

Please circle conditions that you have or have had in the past.

Current  Past         Muscle or joint pain _____________________________________

Current  Past        Muscle or joint stiffness _____________________________________

Current  Past        Numbness or tingling _____________________________________

Current  Past        Swelling _____________________________________

Current  Past        Bruise easily _____________________________________

Current  Past        Sensitive to touch/pressure _____________________________________

Current  Past        High/Low blood pressure _____________________________________

Current  Past        Stroke, heart attack _____________________________________

Current  Past        Varicose veins _____________________________________

Current  Past        Shortness of breath, asthma _____________________________________

Current  Past        Cancer _____________________________________

Current  Past        Neurological (e.g. MS, Parkinson’s, chronic pain) _____________________________________

Current  Past        Epilepsy, seizures _____________________________________

Current  Past        Headaches, Migraines _____________________________________

Current  Past        Dizziness, ringing in the ears _____________________________________

Current  Past        Digestive conditions (e.g. Crohn’s, IBS) _____________________________________

Current  Past        Gas, bloating, constipation _____________________________________

Current  Past        Kidney disease, infection _____________________________________

Current  Past        Arthritis (rheumatoid, osteoarthritis) _____________________________________

Current  Past        Osteoporosis, Osteopenia, degenerative spine/disk_____________________________________

Current  Past        Scoliosis _____________________________________

Current  Past        Broken bone(s) _____________________________________

Current  Past        Allergies _____________________________________

Current  Past        Diabetes _____________________________________

Current  Past        Endocrine/thyroid conditions _____________________________________

Current  Past        Depression, anxiety _____________________________________

Current  Past        Memory Loss, confusion, easily overwhelmed _____________________________________

Any additional information you would like to share: ___________________________________________________________________________________________ __________________________________________________________________________________________

Consent for Treatment: If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature: _____________________________________________________________ Date: ____________

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