630-236-8600 / 630-708-2225

Massage Therapy

Paperwork must be completed prior to your visit so we can spend your scheduled appointment time completing your exam and answering any questions/concerns you may have. If you do not have access to a printer, please arrive 15 minutes prior to your appointment to complete these forms at our office. We look forward to meeting you!

Please click DOWNLOAD to complete your massage therapy paperwork. Feel free to contact us if you have any questions.

Complete the pdf forms and save the file on your computer. Print all forms and sign where applicable. Bring your completed forms with you to your scheduled appointment along with your insurance information.

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Phone Numbers
IN CASE OF EMERGENCY CONTACT
History

Is your complaint due to

Accident
Injury at work
Injury at home
Lifting
Falling
Stress
Auto Accident
Sports
Medical Information

Medications, Allergies, Supplements

Medications Allergies Vitamins / Herbs / Minerals
Yes   No
Yes   No
Yes   No
Please Check All That Apply
Autoimmune Disease
Broken Bones
Dizziness
High Cholesterol
Paralysis
AIDS/HIV
Burns
Shoulder Pain
Insomnia
Prosthetics
Anemia
Cancer/Tumors
Epilepsy
IUD
Pregnant
Arthritis
Chronic Bronchitis
Fatigue
Joint Pain
Rash
Asthma
Circulatory Problems
Fractures
Kidney Disease
Sinusitis
Athlete's Foot
Constipation
Headaches
Liver Disorders
Skin Problem
Heart Diseas
Contact Lenses
Hernia
Lung Disease
Sciatica
Back Pain
Cuts or Sores
Herpes
Stroke
Diabetes
High/Low BP
Ulcers
Varicose Veins
Bruise Easily
Pain Drawing

Key

Mark an X on the picture where you continue to have pain, numbness, or tingling

Use Letters below to indicate type and location of Discomfort
A = Ache B = Burning
C = Stabbing N = Numbing
P = Pins & Needles O = Other
pain drawing
 

I understand the therapy I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session(s), 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 soft tissue work should not be construed as a substitute for medical examination, diagnosis, or treatment. Because soft tissue work 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 practitioners fault should I forget to do so. It is also understood that any illicit or sexual suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for full payment of the session.

(Parent/Guardian Signature if under the age of 18)

 
 
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