JAH WELLNESS LLC FORM Download Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email Occupation Have you received massage therapy? Yes No Type of massage experienced (Swedish, shiatsu, deep tissue, etc.) Are you currently taking any medications? Yes No If yes, please list name and reason for medications: Are you currently seeing a healthcare professional? Yes No If yes, please list names and reason/treatment: Please review this list and check those conditions that have affected your health either recently or in the past. Place a checkmark next to the condition. arthritis depression, panic disorder, other. diabetes condition blood clots diverticulitis broken/dislocated bones back problems bruise easily shingles surgery heart conditions cancer headaches chronic pain high blood pressure constipation/diarrhea hepatitis (A, B, C, other) autoimmune condition stroke whiplash herpes communicable diseases insomnia muscle strain/sprain pregnancy skin conditions scoliosis stroke seizures TMJ disorder If any of the above needs to be detailed or if there is anything else to share, please do so: Do you have any of the following today? skin rash cold/flu open cuts severe pain anything contagious injuries/bruises Do you have allergies to: medications foods, nuts (etc.) skin care products environmental allergens (dust, pollen, fragrances) If any of the above are checked, please give details: Are you wearing: contact lenses hearing aid hairpiece Please note if any, the areas in which you are feeling discomfort. Signature * Date * MM DD YYYY Thank you!
