Client History Form — Amanda Wongsonegoro, CMT

Date of Visit

Street Address

Date of Birth

Email

Occupation

1. Do you receive chiropractic care? Please list the reason:

2. How does your energy feel today? Are you mentally or emotionally drained? Sore from physical exertion?

6. Do you exercise regularly? How many times a week? What do you do?

7. What is your goal for this session today?

Please initial to accept and agree to receive massage from Amanda Wongsonegoro. I have the right to stop the session for whatever reason. I will communicate to the massage therapist if the pressure is too little or not enough.

TERMS

• I understand that all information that passes between us will remain confidential. • I understand that the massage therapist does not diagnose illness, disease, or any physical or mental disorder; does not prescribe medical treatment or pharmaceutical, and does not do any spinal manipulations. It is clear to me that this massage is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment. • I have stated all my known medical conditions and take it upon myself to update it during subsequent visits. • I will comment on the comfort or discomfort of the massage at all times. I will ask for less or more pressure depending on my comfort level during the session. • I will not exercise after the session on the day it is given. I will drink more water than if I had not received a massage. • I will notify the therapist at least 24 hours in advance if I need to cancel my appointment. If I do not notify her I will still pay for the session. • The therapist will call me if I am running more than 10 minutes late for a session. • 30 minute sessions will be paid in full with no service. If it is a 60 minute, the balance of the time will be honored. If it is a 90 minute, the time left will be utilized for a massage session. All sessions will be paid for in full. • If I am under the age of 18 my parent(s) give consent to receive therapeutic massage. A signature from either parent must be on this form. • I release the massage therapist from all liability as I am responsible for communicating my medical conditions, medications, and comfort level.

Please initial to agree and accept terms.

Client Health History Form

Petaluma Family Chiropractic

Citrine

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