CLIENT HEALTH INFORMATION SHEET PERSONAL DATA: Name: ________________________________ Date: ______________________________ Birthday: ______________________________ Phone (home):_______________________ Address: _______________________________ Phone (cell): ________________________ City/State/Zip: ________________________________________________________________ Primary Health Care Provider: _____________________ Phone: ______________________ Permission to consult with primary provider? _______ Yes _______ No Who referred you to this office? __________________________________________________ Advertisement: _______ Sign: _______ Other: _______ MASSAGE HISTORY/TREATMENT INFORMATION * Have you ever received a professional massage? _____ Yes _____ No * Preferred massage treatment product. ____ Lotion ____ Oil ____ Aromatherapy * What are your intentions/expectations for this visit? __________________________ ______________________________________________________________________ * What type of pressure do you prefer? _____ Light _____ Medium _____ Deep * Please check the areas of your body that you give permission to receive massage: __ Back __ Legs __ Arms __ Neck __ Head __ Face __ Buttocks __ Abdomen CURRENT MAJOR COMPLAINT INFORMATION (If you do not have current health concerns, please go to health history section) * Present symptoms: What is your major complaint or condition that you want to improve? ______________________________________________________________ _______________________________________________________________________ * When did you first notice major complaints? _________________________________ * What activities aggravate the condition? ____________________________________ * What activities alleviate the condition? _____________________________________ * Is this condition getting progressively worse? _____ Yes _____ No Please explain __________________________________________________________ * Does this condition interfere with: Work? ___ Yes ___ No Sleep? ___ Yes ___ No Daily routine? ___Yes ___ No Please explain: _________________________________________________________ * What have you done to get relief? __________________________________________ * Has there been a medical diagnosis? ___ Yes ___ No
If so, by whom? ________________________________________________________ Please explain __________________________________________________________ HEALTH HISTORY * Are you now under medical/therapeutic treatment? ___ Yes ___ No If yes, for what condition? _______________________________________________ * List any medications (including aspirin) and nutritional supplements you are taking: ______________________________________________________________________ * List stress reduction and exercise activities. Include frequency: _________________ ______________________________________________________________________ * Please list (date and description) any accidents or operations: ___________________ ______________________________________________________________________ MUSCULO-SKELETAL SKIN ___ Bone or joint disease ______________________ ___ Allergies __________________ ___ Tendonitis ______________________________ ___ Rashes ____________________ ___ Bursitis ________________________________ ___ Athlete’s foot _______________ ___ Broken/fractured bones ____________________ ___ Warts ____________________ ___ Arthritis ________________________________ ___ Other _____________________ ___ Sprains/strains ___________________________ ___ Low back,hip,leg pain _____________________ DIGESTIVE ___ Neck,shoulder,arm pain ____________________ ___ Constipation ___ Headaches/head injuries ___________________ ___ Gas/bloating ___ Spasms/cramps __________________________ ___ Diverticulitis ___ Jaw pain/ TMJ ___________________________ ___ Irritable bowel syndrome ____ ___ Lupus _________________________________ ___ Other _____________________ ___ Other __________________________________ CIRCULATORY NERVOUS SYSTEM ___ Heart condition __________________________ ___ Herpes/shingles ____________ ___ Varicose veins ___________________________ ___ Numbness/tingling __________ ___ Blood clots _____________________________ ___ Chronic pain _______________ ___ High blood pressure ______________________ ___ Fatigue ___________________ ___ Low blood pressure ______________________ ___ Sleep disorders _____________ ___ Lymphedema ___________________________ ___ Other ___ Breathing difficulty _______________________ ___ Sinus problems __________________________ REPRODUCTIVE ___ Allergies _______________________________ ___ Pregnant? Stage ____________ ___ Other __________________________________ ___ PMS _____________________ AUTO IMMUNE/INFECTIOUS DISEASE OTHER ___ Fibromyalgia ___________________________ ___ Cancer/tumors _____________ ___ Chronic fatigue _________________________ ___ Diabetes __________________ ___ Rheumatoid arthritis _____________________ ___ Eating disorders ____________ ___ Lupus ________________________________ ___ Depression ________________ ___ Epstien Barr ____________________________ ___ Drug/alcohol addiction _______ ___ Other _________________________________ ___ Nicotine/caffeine addiction ____ It is my choice to receive massage treatment. I realize that the treatment is being given for the well-being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. I agree to communicate with my practitioner any time that I feel like my well-being is being compromised.
I understand that massage practitioners do not diagnose illness, disease or any physical or mental disorder; nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations. I acknowledge that massage is not a substitute for medical examination or diagnosis, and that it is recommended that I see a primary health care provider for that service. I have stated all medical conditions that I am aware of and will update the massage practitioner of any changes in my health. Signature: ____________________________________ Date: _______________________
João Carlos Correia Introdução: A cultura dos mass media vive sob suspeita. Por um lado, sempre se fez sentir a vocação dos mass media para despertar e gerir a emoção, o que desde logo remete para as categorias do espectáculo e da subjectividade. Por outro lado, sempre se suspeitou da manipulação do desejo como forma de impedir o uso da razão, o que leva a pensar na fig
Assessing efficacy of stuttering treatments$Department of Psychology, University College London, Gower Street, London WC1E 6BT, UKReceived 20 September 2000; received in revised form 27 February 2001; accepted 15 June 2001Efficacy has been defined as the extent to which a specific intervention, procedure,regimen, or service produces a beneficial result under ideally controlled conditions whena