Circle Of Light

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Contraindications & Client Intake Form

Please read all the below contraindications for massage & fill out print and fill out the client intake form and bring with you to your 1st massage appointment.  If you are receiving a cupping treatment also, you will need to fill out the separate form for cupping too.  Thank you.

Contraindications for Massage

 

NO MASSAGE

Bites CONTAGIOUS and insect or snake bites

Contagious or Infectious Diseases – including colds & flu - expose therapist to disease, weaken immune system, and spread infection through lymphatic system (tuberculosis/meningitis/encephalitis/MRSA)

Fever– body fighting an infection

Neuritis – inflamed peripheral nerves resulting in pain and loss of function

Pregnancy – No massage until after 1st trimester

Recent Operations - Postoperative Precautions  or Acute Injuries – Doctors permission within 6 months

Skin Diseases – Herpes …

Substance Abuse (drugs or alcohol) – including prescription pain medications

 

AVOID AREA

Abrasions

Allergy Symptoms & Skin Rashes –lesions, rashes, hives, psoriasis, eczema, poison ivy, poison oak, and poison sumac

Bone Fractures – AVOID AREA UNLESS DOCTOR APPROVED

Bruising

Cuts

Eczema (rough, blisters, inflamed skin

Edema (excessive fluid retention)

Eyes – MUST REMOVE CONTACT LENSES IF MASSAGE EYES

Hernia

HIV – (wear gloves if open legions)

Inflammation – AVOID if red, painful & swelling

Psoriasis

Pregnancy –AVOID abdomen & feet & no aromas

Skin Infections –boils, abscesses …

Skin Lesions, Open Wounds, Sores, Blistering

Sunburn

Ulcers – AVOID abdomen

Undiagnosed lumps or bumps or pain

Varicose veins

 

NEED DOCTORS APPROVAL or REFER TO DOCTOR

All conditions already being treated by a doctor

Accident – recent

Angina – pain in chest

Asthma - chronic

Bell’s palsy, trapped & pinched nerves

Cancer – CASE BY CASE BASIS – NEED DOCTOR PERMISSION – AVOID tumor site, abdominal region, & sometimes quadrant.   AVOID  lymph node area if removed & below limb.  AVOID radiation region.  Chemotherapy & radiation prone to infection – AVOID OILS & LOTIONS – Okay in terminal cases

Cardio – Vascular / Heart Conditions-   

                Artherosclerosis (plaque) – AVOID CAROTID ARTERIES IN NECK

Blood Clotting (embolism or thrombus) –can get bruising or hemorrhaging from deep tissue

                Heart Attack, Conditions, Angina, Pacemakers

                High Blood Pressure (light massage)

Hypertension (high blood pressure)

Pacemaker (avoid area)

Phlebitis – inflammation of veins – usually in legs

Thrombophlebitis (deep leg veins) –can move blood clots & cause death

Diabetes

Dizzy & Nauseated

Eczema -Extreme (rough, blisters, inflamed skin)

Edema- Extreme (excessive fluid retention)

Epilepsy

Fatigue (Extreme OR Sudden)   –early symptoms of life threatening degenerative diseases – diabetes, cardiovascular, cancer, auto immune disease, chronic infection – REFER TO DOCTOR

Gynecological Infections

Inflammation  (“it is”)–REFER TO DOCTOR –could be fracture, dislocation, rheumatoid arthritis (joints), dermatitis (skin) …

Kidney Infection – sever loin pain with fever – REFER TO DOCTOR

Nervous or Psychotic Conditions

Neuritis – Nerve Inflammation, trapped or pinched nerves – REFER TO DOCTOR

Osteoporosis (Severe – light massage)

Peritonitis – abdomen ridged or extreme pain (fever) - inflammation of abdomen – REFER TO DOCTOR

Psoriasis – Extreme - (a skin disease marked by red, itchy, scaly patches)

Pregnancy – NEED DOCTOR APPROVAL in 1st trimester or medical issues

Severe Pain –– can’t sleep well, or lie down comfortably - REFER TO DOCTOR

Other – Per Doctor’s request

 

NO DEEP TISSUE

Blood Clotting (embolism or thrombus)

Chronic Pain –Autoimmune Diseases – lupus, scleroderma, rheumatoid arthritis…

Elderly (frail) – bruising

High Blood Pressure

Fatigues, excessive stress, & unable to relax

Loss of Sensation (Numbness) –can bruise tissue.  Could be late-phase diabetes, syringo-myelia, spinal cord or brain damage, nerve root or peripheral nerve compression, intoxication, drug use, or stroke

Osteoporosis – gentle massage only

Metal in body

Some medications –if taking anticoagulant drugs… Per Doctor

Thrombophlebitis (deep leg veins)

*****************************************************************************************************

Consent for areas worked on:

Written _______

Verbal _______

Please answer yes or no to the below areas of treatment:

Face _____

Head _____

Pecs _____

Between Breasts _____

Breasts ______  (Dr. approved for cancer clients) _______

Abdomen

Glutes

Feet

Other area's to avoid ____________________________________

Pressure (light, medium or deep) ___________________________

 

In addition to the above, I have reviewed all the contraindications list and affirm that I have no contraindications that will interfere with my treatments.

Client Signature:    ___________________________________________    

 

Client Information

Name:  _______________________________________________________________________________

Phone:  ______________________________________________________________________________

DOB:  __________________________

Address:  _____________________________________________________________________________

Email Address:  ________________________________________________________________________

Referred By:  __________________________________________________________________________

In Case of Emergency Name & Number:  ____________________________________________________

Occupation:  __________________________________________________________________________

Sex:  _______________________

Physician Name & Number:  _____________________________________________________________

Health Insurance Carrier:  _______________________________________________________________

Please take a moment to carefully read the following information and sign where indicated.  If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated.  A referral from your primary care provided may be required prior to service being provided.

 

Have you ever experience a professional massage or bodywork session?  _________________________

How recently?  _________________________

Please indicate with an X if you have any of the following:

Do you frequently suffer from stress?  ________

Do you have diabetes?   ________

Do you experience frequent headaches?  ________

Are you Pregnant?   ________

Do you suffer from arthritis?  ________

Are you wearing contact lenses?  ________

Are you wearing dentures?  ________

 

Do you have high blood pressure?  ________

If yes to previous question, are you taking medication for this?   ________

Do you suffer from epilepsy or seizures?  ________

Do you suffer from joint swelling?  ________

Do you have varicose veins?  ________

Do you have any contagious diseases?  ________

Do you have osteoporosis?  ________

Do you have allergies?  ________

Do you bruise easily?  ________

Have you had any broken bones in the past two years?  _______________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you been in an accident or suffered and injuries in the past two years?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you have tension or soreness in a specific area?  Please explain:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you have cardiac or circulatory problems?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you suffer from back pain?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you have numbness or stabbing pains anywhere?  Where?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Are you very sensitive to touch or pressure in any area?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever had surgery?  Explain:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

Do you have any other medical conditions, or are you taking any medications I should know about?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension.  If I experience any pain or discomfort during the session, 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 massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any medical or physical ailment of which I am aware.  I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such.  Because massage/bodywork 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 practitioner’s part should I fail to do so.  I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate terminate of the session, and I will be liable for payment of the scheduled appointment.

 

Client signature ________________________________________________________________________

Date___________________________

Practitioner signature ___________________________________________________________________

 

Consent to treatment of Minor:  By my signature below, I hereby authorize Sheri Newcombe to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.

Signature of Parent or Guardian ___________________________________________________________

Date __________________________



 

 

 

 

 

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