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Financial Aid Application

May we know you

First Name *

Middle Name

Last Name *

Email Address *

Phone *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country

Birth Date *

Emergency Contact Information

First Name *

Last Name *

Phone Number *

Occupation

History of Pathology

List Areas of Discomfort or Pain *

Describe Onset of Discomfort or Pain *

Rate of Pain Today *1 - very little2345678910

Frequency - please select the most accurate *ConstantOn/OffAt RestWith ActivityOther

Other *

At what time of the day is the pain at it's worst? *MorningAfternoonEveningDuring SleepOther

Other *

Have you ever injured this area before? *YesNo

Have you ever been in an accident (automobile, work, falls, etc.) ? *

If yes, please explain and include dates.

List all related treatments received for this injury. *

Have you ever received therapeutic massage for a specific problem or injury? *YesNo

Please give date of last massage *

Was the treatment used effective? *YesNo

Is there anything that you do that creates, increases or decreases pain? *YesNo

If there's anything that you do that creates, increases or decreases pain, please explain. *

What are the physical duties required of your occupation? *

What activities/hobbies do you enjoy? *

Please list exercise and stress reduction activities (including frequency). *

In what position do you most often wake up? *

Other *

Are you currently seeing any other healthcare professional? *YesNo

If you are you currently seeing any other healthcare professional, please list here. *

Medical Symptoms

Please check any symptoms that apply to you and indicate right or left when applicable:

Head

TemplesForeheadTop of headIn the eyesEntire headBase of skullDizzinessFaintingLight-headednessPain in earsRinging in earsOther

Other *

Neck

StiffnessPain at neck shoulder junctionPain when turning headPain with side to side movementsNeck feels out of placeMuscle spasm in neckGliding/Grating sound with neck movementDiagnosed bone spursDiagnosed disc herniationOther

Other *

Shoulders

Pain in shoulderFrontBackSidePain deep in shoulder jointDiagnosed bursitisDiagnosed ArthritisCan't raise arm above shoulder levelCan't raise arm over headOther

Other *

Arms & Hands

Pain in upper armPain in forearmPain in wristPain in fingersSensation of pins & needles in armSensation of pins & needles in fingersFingers go to sleepHands coldSwollen joints in fingersSore joints in fingersDiagnosed arthritisLoss of grip strengthOther

Other *

Mid-back

Mid-back painPain between shoulder bladesPain up/down backPain across mid backPain with breathingOther

Other *

Low Back

Low back painLow back pain is worse when workingLow back pain is worse when liftingLow back pain is worse when stoopingLow back pain is worse when standingLow back pain is worse when sittingLow back pain is worse when bendingLow back pain is worse when coughingPinched nerve in low backLow back feels out of placePain up/down low backPain across low backDiagnosed disc herniationOther

Other *

Hip

Pain in buttocksPain in buttocks when standingPain buttocks in buttocks when sittingPain on side of hipPain deep in hip jointPain on sit boneDiagnosed bursitisDiagnosed arthritisOther

Other *

Legs and Feet

Pain down RIGHT legPain down LEFT legPain down BOTH legsLeg crampsPin & Needles in RIGHT legPin & Needles in LEFT legNumbness in RIGHT legNumbness in LEFT legNumbness in RIGHT footNumbness in LEFT footNumbness in toesFeet feel coldCramps in RIGHT footCramps in LEFT footSwollen RIGHT ankleSwollen LEFT AnkleSwollen RIGHT footSwollen LEFT footPain in RIGHT FootPain in LEFT FootPain in RIGHT kneePain in LEFT kneeDiagnosed ArthritisOther

Other *

Policies & Agreement

Massage Policies

Client services and chart information are confidential. Written authorization is required from you to release any information.

Please turn off your cell phone for optimal relaxation
Your scheduled session is set aside for you. We do not double book appointments
Please reschedule your session if you are more than 15 minutes late
24 hour cancellation notice is required to avoid being charged for your session
You will be draped and at no time will genitalia or breast tissue be exposed
You will have a consultation with your therapist to discuss your session
Should the session require, after your therapist has left the room, you may disrobe to your comfort level
I understand that my therapeutic massage therapist or I may end the session at any time for any reason
Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.

Signature *

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Please do not fill in this field.

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