Marian Wolfe Dixon, MA, LMT (Oregon License #3902)
www.marianwolfedixon.com (phone) 503-232-7282
Brief Massage History Questionnaire
Please complete this brief questionnaire so that I may better understand your history regarding massage. If patient is a minor, please have legal guardian complete and sign. This will enable the massage to be more effective. All information is kept in strict confidence. Thank you.
Name _________________________________Date___________DOB_____________Phone____-___________ C W H
Address_____________________________________ City_______________ State_________ Zip__________
email_____________________________________ How did you hear about me? _______________________
Emergency contact and phone_________________________________________________________________
Y N Have you had a professional massage before?
Y N Are you taking any drugs or medications? (If yes, explain here.)
Y N Are you currently under the care of a health care practitioner?
Health Care Practitioner Name _______________________email ___________________Phone______________ C W H
Reason for Tx ______________________________________________________________
Y N Do you have an area or areas of the body that need special attention? (Where?) _________________
Y N Regions of your body that you do not want massaged? (Where?) _____________________________
What, if anything, makes your symptoms better?______________________________________________________
What, if anything, makes your symptoms worse?______________________________________________________
What are your goals for your massage session today? _________________________________________________
Have you experienced any of the following? (one check if ever experienced, two checks if currently an issue)
______ circulation problems ______ broken bones (recent?) ______ pregnancy # _____ live birth(s) #
______ heart disease ______ osteoporosis ______ anxiety
______ high (or low) BP ______ skin allergies/ sensitivities ______ history of abuse
______ varicose veins ______ recent illness/injury ______ depression
______ lack of feeling in parts of body (Where?) ___________________________________
_______contagious disease(s) ______ mental/emotional diagnosis
______ joint swelling/inflammation ______ migraines ______ trouble sleeping
______ open cuts/sores ______ headaches ______ cancer
______ diabetes ______ arthritis ______ chemotherapy
______ seizures _____ lymph node removal ______ radiation
______ other
The purpose of massage is to maintain good health and physical condition. I understand that LMT’s may not diagnose or treat disease and that massage should not take the place of a doctor’s care. Either the LMT or the patient may terminate the session should either be experiencing discomfort during the massage. Discomfort may include (but is not limited to) physical pain, sexually suggestive behavior or personal remarks or requests. Payment is due at the time of the appointment and 24 hournotice is required to avoid a no show fee / payment for a missed session. My initials signify that I understand and agree to abide by these policies and procedures.__________
www.marianwolfedixon.com (phone) 503-232-7282
Brief Massage History Questionnaire
Please complete this brief questionnaire so that I may better understand your history regarding massage. If patient is a minor, please have legal guardian complete and sign. This will enable the massage to be more effective. All information is kept in strict confidence. Thank you.
Name _________________________________Date___________DOB_____________Phone____-___________ C W H
Address_____________________________________ City_______________ State_________ Zip__________
email_____________________________________ How did you hear about me? _______________________
Emergency contact and phone_________________________________________________________________
Y N Have you had a professional massage before?
Y N Are you taking any drugs or medications? (If yes, explain here.)
Y N Are you currently under the care of a health care practitioner?
Health Care Practitioner Name _______________________email ___________________Phone______________ C W H
Reason for Tx ______________________________________________________________
Y N Do you have an area or areas of the body that need special attention? (Where?) _________________
Y N Regions of your body that you do not want massaged? (Where?) _____________________________
What, if anything, makes your symptoms better?______________________________________________________
What, if anything, makes your symptoms worse?______________________________________________________
What are your goals for your massage session today? _________________________________________________
Have you experienced any of the following? (one check if ever experienced, two checks if currently an issue)
______ circulation problems ______ broken bones (recent?) ______ pregnancy # _____ live birth(s) #
______ heart disease ______ osteoporosis ______ anxiety
______ high (or low) BP ______ skin allergies/ sensitivities ______ history of abuse
______ varicose veins ______ recent illness/injury ______ depression
______ lack of feeling in parts of body (Where?) ___________________________________
_______contagious disease(s) ______ mental/emotional diagnosis
______ joint swelling/inflammation ______ migraines ______ trouble sleeping
______ open cuts/sores ______ headaches ______ cancer
______ diabetes ______ arthritis ______ chemotherapy
______ seizures _____ lymph node removal ______ radiation
______ other
The purpose of massage is to maintain good health and physical condition. I understand that LMT’s may not diagnose or treat disease and that massage should not take the place of a doctor’s care. Either the LMT or the patient may terminate the session should either be experiencing discomfort during the massage. Discomfort may include (but is not limited to) physical pain, sexually suggestive behavior or personal remarks or requests. Payment is due at the time of the appointment and 24 hournotice is required to avoid a no show fee / payment for a missed session. My initials signify that I understand and agree to abide by these policies and procedures.__________
