Rosemont Pain Relief Therapy

IMPORTANT! PLEASE COMPLETE THIS FORM Answer all question and fill-in all blanks. Thank you. Dennis Wilson

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Employment

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  • Alabama
  • Alaska
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  • California
  • Colorado
  • Connecticut
  • Delaware
  • District of Columbia
  • Florida
  • Georgia
  • Hawaii
  • Idaho
  • Illinois
  • Indiana
  • Iowa
  • Kansas
  • Kentucky
  • Louisiana
  • Maine
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
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General and Medical Information
General and Medical Information
Height
Height
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Weight
Weight
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Birth Date
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Are you currently experiencing any of the following conditions?
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Please check any of the following conditions below that currently affect you or that you have experienced in the past five years.
MUSCULOSKELETAL
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CIRCULATORY
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RESPIRATORY
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DIGESTIVE
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SKIN
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NERVOUS SYSTEM
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OTHER
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Signature Page
Signature Page
Please take a moment to carefully read the following information and sign where indicated.
I understand myofascial release/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 mental or physical ailment that I am aware. I further understand that massage/bodywork practitioners do not diagnose physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because myofascial release/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 forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I understand I will be CHARGED FOR APPOINTMENTS I CANCEL OR MISS WITHOUT 24 HOURS PRIOR NOTICE of my scheduled myofascial release/bodywork session. I also understand if I arrive late, I will receive the remainder of my time but will be liable for payment in full.
Signature
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Thank you
Dennis Wilson
Rosemont Therapy