Om Chakra Client Information

This information is necessary for us to provide you with a massage session that best meets your needs. Please take the time to answer all of the questions below as accurately as possible. The information you provide is strictly confidential.

This form will be sent to Om Chakra so they can prepare your session.

*  
Indicates Required Field

General Information

Name *      Date of Initial Visit
Address
City     State     Zip
Date of Birth  /   / 
Home Phone    Cell Phone    Work Phone
Occupation    Email *  
Emergency Contact *     Phone *  
How did you hear about Om Chakra Wellness Center?
Have you ever had a professional massage?  
If yes, what type?
   

Medical Information

Are you currently under the care of a physician for any reason?  
If yes, please explain
Physician's Name    Phone

With certain medical conditions and symptoms, massage should not be performed and permission from your physician may be required prior to service being provided.

Do we have permission to contact your physician?  
Are you currently taking any medications?  
If yes, please list them including any vitamins and herbal supplements
Are you pregnant?
If yes, how far along are you?
Please check any medical conditions that apply






* If Cancer, please provide Diagnosis date     Last Treatment 
** If Other, please explain
   

Lifesyle Information

Do you exercise?
If yes, what kind and how often?
Do you use?
How much water do you drink daily?
How would you rate your stress level on a scale of 1 (lowest) to 10 (highest)?
Where do you hold tension in your body?

I understand that the massage I receive is provided for the basic purpose of relaxation and the relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure/stroke may be adjusted to my level of comfort. I further understand that massage should not be performed under certain medical conditions. I affirm that I have stated all of my known conditions and answered all of the above questions honestly. I agree to keep Om Chakra updated as to any changes in my medical/health status. I assume all legal responsibilities for my health and wellbeing. I release Om Chakra from any and all present and future responsibility. I understand that Om Chakra reserves the right to terminate my session if deemed necessary.

Please select one. You will be asked to sign your registration form at your appointment.  
   
 

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