Scalp Massage Therapy Health Questionnaire Form (required)

    Full name : (required)

    Email : (required)

    1. Cardiovascular conditions (Please describe):

    2. Pulmonary conditions (Please describe):

    3. Neurological conditions (Please describe):

    4. Musculoskeletal conditions (Please describe):

    5. Infectious conditions (Please describe):

    6. Psychological conditions (Please describe):

    7. Sensory loss (Please describe):

    8. Gynecological conditions (Please describe):

    9. Allergies or skin conditions (Please describe):

    10. Medical implants (Please describe):

    11. Any other conditions or symptoms that have not been mentioned above? If so (Please describe):

    12. Have you had any major accidents, injuries, or surgeries? If so (Please describe):

    13. Are you currently taking any medication? If so (Please describe):

    TODAY’S TREATMENT INTAKE(required)

    1. What is your reason for seeking treatment today?
    2. Do you have any treatment goals?
    3. Have you received massage therapy before?

    SCALP HISTORY

    Previously Chemical? YesNo
    Current Hair Loss? YesNo
    Dry scalp and/or dandruff? YesNo

    HOME REGIME

    Hair care products :
    Frequency of washing :
    Frequency of thermal styling :

    Other

    Percentage (%) of Gray:

    Hair Type: (Please check all that apply)
    CoarseMediumFine


    Hair Density: (Please check all that apply)
    ThickAverageFine

    Additional Comments:





    INFORMED CONSENT FOR TREATMENT

    I, , acknowledge that the massage therapy provided to me at Album Hair is intended to promote
    relaxation, reduce pain caused by muscle tension, improve circulation, and provide a positive
    experience of touch.
    The general benefits of massage, possible contraindications, and the treatment procedure has
    been explained to me. Contraindications for massage include, but are not limited to: fever,
    uncontrolled diabetes or hypertension, acute local inflammation, infectious skin rashes, and
    suspected DVTs/phlebitis.
    I acknowledge that massage therapy is not a substitute for medical treatment or medications
    and that it is recommended I concurrently work with my primary physician for any medical
    condition for which I was diagnosed.
    I take responsibility for alerting my therapist to any physical, mental or emotional changes that
    occur with my health. I acknowledge that the therapist’s knowledge about my health background
    is very important before I receive a massage and acknowledge that my records will be kept
    confidential. I am aware that the massage therapist does not diagnose illness or disease, and
    does not prescribe medications.
    I have informed the massage therapist of all known physical conditions, medical conditions,
    medications and have authorized my caregivers to provide information concerning my physical
    and medical condition. I acknowledge that the Massage Therapist reserves the right to postpone
    my appointment if a physician’s approval is needed before receiving massage therapy.


    Client's-Name
    Client's Signature
    Date