Medical History Form - Omaha Blue Waves Martial Arts

Omaha Blue Waves Massage & Martial Arts
Medical History Form ,
Please mark (X) all conditions that apply now. Put a P for past conditions. Put an F for
family history of illness.
_Headaches,
migraines
_Vision
problems, contact lenses
__ Hearing problems, deafuess
_Injuries
to face or head
_Sinus problems
_Dental
bridges, braces
_Jaw pain, TMJ problems
_Asthma
or lung conditions
_Constipation,
diarrhea
Hernia
_Birth
control, IUD
__ Abdominal or digestive problems
_chronic
pain
_fatigue
_muscle
or joint pain
_tension,
stress
_muscle,
bone injuries
_depression
__ numbness or tingling
_sleep
difficulties
_sprains,
strains
_allergies
_rash,
athletes foot
_arthritis,
tendonitis
_cancer,
tumors
infectious disease
blood clots
_spinal
column disorders
varicose veins
diabetes
""--pregnancy
_high/low
blood
_heart,
circulatory problems
pressure
other medical conditions not listed
Five Elements Massage, Martial Arts and Oriental Health Center, LLC
Dba - Omaha Blue Waves Martial Arts & Massage Therapy
Name:
(H) Phone:(
)
-
Address:
(W) Phone:(
)
-
City/State/Zip:
Email:
DOB:
Month
Day
Year
I
Sex:
Male
Female
r.ird" On"
I
Parental Information for Minor Child
SSN:
Optional
Custodial Parent Yes
NO
Circle One
Parent Name:
H/Phone:(
)
-
Parent Address:
W/Phone:(
)
-
City/State/Zip:
Email:
Informed Liability Waiver, Consent to Treat, Covenant Not to Sue, Acknowledgement of Disclosure
Information, and Notice of Privacy Practice Receipt
I voluntarily give Five Elements Massage, Martial Arts, and Oriental Health Center, LLC and its staff members my consent to provide me (or my minor
child) the health care service or massage I have requested. Furthermore, I (on behalf of my heirs, personal representatives, executor, and administrator)
hereby waive, release, remise, covenant not to sue and forever discharge from any claims and liabilities whatsoever without limitations that I have which
arise against Five Elements Massage, Martial Arts, and Oriental Health Center LLC, its owners, and staff members for any service that they have
provided to me (or my minor child) or for any accident I (or my minor child) may have while on any property owned, leased or used by them.
I understand that Massage Therapy is being provided to me by a Massage Therapist licensed in the state of Nebraska. I understand that
massage/bodywork is performed for the purpose of stress reduction or relief from muscular tension, spasm, or pain, and to increase circulation. I, also,
understand that is my responsibility to communicate any issues I have with my treatment or relaxation massage to the staff member working with me. If I
experience any pain or discomfort during M!Y treatment, I will immediately inform the massage therapist so that the pressure or methods can be adjusted
to my comfort level. I understand that massage therapists do not diagnose allopathic illnesses or disease or perform any spinal manipulations, nor do
they prescribe any medical treatments, and nothing said or done during the session should be construed as such. I acknowledge that
massage/alternative health care is not a substitute for medical examination or diagnosis and that I should see a licensed physician for those services.
Because different modalities should not be performed under certain circumstances I agree to keep the staff updated on any changes in my health profile,
and I release the staff from any liability if I fail to do so. Furthermore, I understand that the staff does not recommend that I start a physical training
program, modify my diet, or take herbs without consulting a licensed health care professional. Educational information on oriental medicine and martial
arts are provided for the preservation of the arts and for my personal enrichment. I understand this company will not accept liability for my use or misuse
of that information.
Signature
Date:
of Client:
Signature of Client's
(Minor Child)
Date:
Parent:
BWe Referral and/or Physician
Referral
Information
BWC#:
-
Physician Name:
Phone#:
Physician Address:
Fax#: (
City/State/Zip:
Form Revision 5/07/05
(
)
)
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