~ Relax to the Max - Massage Therapy || Stress Relief, Wilmington, NC ~


	Name:		Telephone:
	Address:		City:
	State:		Zip:
	Referred By:		Telephone:
	Emergency Contact:		Telephone:


	Occupation:		Birthdate:
	Physician:		Sex:

	I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. 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 or 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 the 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.
	Please mail me information and updates about Relax to the Max and this website


Please take a moment to carefully read the following information. If you have a specific medical condition or specific symptoms, massage/bodyworkmay be contraindicated. A referral from your primary care provider may be required proir to service being provided.
Yes	No		Yes	No
		Do you have diabetes?			Do you suffer from epilepsy or seizures?
		Do you experience frequent headaches?			Do you have any contagious diseases?
		Are you pregnant?			Do you have osteoporosis?
		Do you suffer from arthritis?			Do you have allergies?
		Do you have high blood pressure?			Have you had any broken bones in the past two years?
		Are you taking medication for high blood pressure?			Have you been in an accident or suffered any injuries in the past two years?
		Do you have any other medical conditions or are you taking any medications I should know about?			Do you have tension or soreness in a specific area?
Specify:			Specify:

		Have you ever had surgery before?			Do you suffer from back pain?
Specify:			Specify:

		Do you have numbness or stabbing pains anywhere?			Do you suffer from stress?
Specify:			Describe:

		Please contact me to make my appointment

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