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Diana Watson LMT

License no. 27977

Image by Renee Kiffin

Intake Form

Thank you for Booking with me. It would be helpful for me to have a in depth look at your Medical History to best serve you in our session together. Please take some time to fill out the Intake Form prior to our first session together.

First name*

Last name*

Email*

Phone*

Address

Birthday*

Month

Day

Year

Occupation

Emergency Contact Name and Number*

Have you had a professional massage before? If yes, when?

Do you have any areas of broken skin? rash? wound? candida? toe fungus? warts?

Do you have any allergies? (nuts, oils, lotions, fruits) if yes, please list

Are you taking any medications, supplements? Please list, as well as dosage.

Please describe previous injuries, surgeries, causes and dates of occurrences. *

If applicable: Please describe any treatments you have received for these particular issues.

What would you like to address in our treatments together?*

If applicable: How long has this been an issue for you? (Please list onset date) What does it rate on a pain scale from 1-10. (10 being the worst)

Is there anything else you want to share?

The following is to get an idea of your Health History. Please check all that apply: Cardiovascular

Varicose Veins, poor circulation

Congestive Heart Failure

Stroke, Heart Attack

Heart Disease

High or Low Blood Pressure

Embolism

Pacemaker

Thrombosis

The following is to get an idea of your Health History. Please check all that apply: Head and Neck

Dizziness

Tinnitus

Hearing Loss

Sinusitis

Headaches, Migraines

Vision Problems

The following is to get an idea of your Health History. Please check all that apply: Neurological

Tennis Elbow

Golfer's Elbow

Sciatica

Multiple Scoliosis

Sensory Loss

Epilepsy

The following is to get an idea of your Health History. Please check all that apply: Respiratory

Asthma

Bronchitis

Shortness of Breath

Tuberculosis

Emphysema

The following is to get an idea of your Health History. Please check all that apply: Musculoskeletal/Skin

Artificial Joints, Surgical Pins

Arthritis

Osteoporosis

Contact Dermatitis

Psoriasis

Bruise Easily

Eczema

Sunburn

Acne

The following is to get an idea of your Health History. Please check all that apply:

Rheumatoid Arthritis

Fibromyalgia

Anxiety

Depression

Hyper-thyroidism or Hypo-Thyroidism

Acid Reflux,Heartburn,Ulcer

Cancer

Diabetes

HIV/AIDS

Crohn's Disease, IBS,

Uterine Fibroids

Endometriosis

Terms & Conditions: Waiver: I understand that massage therapy is provided for stress reductions, relaxation, relief from muscular tension, and improvement of circulation and energy flow. Please Initial.

If I experience pain or discomfort during the session, I will immediately inform my massage therapist so that pressure/strokes can be adjusted my level of comfort. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.

I understand that massage is not a substitute for medical care and that my massage therapist is not qualified to diagnose, prescribe, or treat mental illness. Please initial.

I affirm that I have notified my massage therapist of all known medical conditions and injuries. I agree to inform the massage therapist of any changes in my health and medical condition and that there shall be no liability on the massage therapist's part should I forget to do so.

I understand that massage is entirely therapeutic and non-sexual in nature. By signing this release, I waive and release my massage therapist from any liability, past, present, and future, relating to massage therapy and bodywork. Please Intial.

I have read and understand the terms and conditions. The information in this form is correct to the best of my knowledge

Signature

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Date

Month

Day

Year

Wise blood Healing LLC. Offering Prenatal, Lymphatic, Deep Tissue Massage.

WISE BLOOD HEALING LLC

5118 SE POWELL BLVD.

AT ACCURATE INJURY CARE & WELLNESS

PORTLAND,OR 97206

P: 971-303-8377

Thursday 9-8
Saturday 9-8

new location
June 1st

Accepting MVA and Workmans Comp Patients

Soon will be Accepting BC/BS, and Providence Patients

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