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Health History Form 

This form is to be filled out for both for Massage and Acupuncture treatments 

Please fill out the following form to help me understand your physical condition and provide a custom treatments.

Medical Health Plan Provider
What does the pain feel like?
Musculoskeletal Conditions
Bladder/Kidney Conditions
Sleep Issues
Bowel Movements
Skin Conditions
Do you find yourself feeling?:
Which emotion best describes your mood majority of the time?

I understand that the massage I recieve is for the purpose of stress reduction and relief of muscular tension, spasm, or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform the therapist or that the pressure or methods used can be adjusted to my comfort level. I understand that massage therapy do not diagnose illness or disease, nor do they perform spinal manipulation or prescribe any medical treatment, and nothing said or done during the session should be considered as such. I acknownlegade that massage is not a substitude for medical examination or diagnosis, and I should see a health care provider for those services. Because massage should not be performed under some circumstance, I agree to keep the massage therapist updated as to any changes in my health, and I release the massage therapist and Holistic health clinic from any liability if I fail to do so. 

“Acupuncture” means the stimulation of a certain point or points near the surface of the body via the insertion of thin needles. The purpose of acupuncture is to prevent or modify the perception of pain and is thus a form of pain control. In addition, through the normalization of physiological functions, it also often serves in the treatment of certain diseases or dysfunctions of the body. Acupuncture includes the techniques of electro-acupuncture, manual stimulation, cupping and/or moxibustion. Slight pain or discomfort at the site of needle insertion, infection, bruises, weakness, numbness, fainting, nausea, and aggravation of problematic systems existing prior to acupuncture treatment. Cupping almost always causes bruising. Unlikely/unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture. By voluntarily signing below, I show that I have read the above consent to treatment, have been told about the risks and benefits of all services  provided by Lindsay Sorensen, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Thanks for submitting!

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