I understand that Deborah Gilmore/Abundant Panacea does not diagnose illness, disease or conditions; nor do they perform spinal manipulations. I have stated all known medical conditions and take it upon myself to keep Deborah Gilmore, RMT, CHC updated concerning my physical health.
I understand that payment is due at the time of treatment unless arrangements have been made otherwise. I also understand that I am responsible for payment if third party payment is not made.
I agree to give 24 hours notice of cancelation, otherwise full payment is expected. Illnesses or unexpected emergencies will be taken into consideration. Please call if you are experiencing symptoms of a contagious illness prior to your appointment.
If you have been receiving massage regularly from me, and for whatever reason, decide you need to discontinue, I ask that you let me know prior to your last session so we can give ourselves time to come to closure.
Abundant Panacea and Deborah Gilmore reserve the right to terminate the massage session at anytime due to inappropriate behavior or health risks.
If you are a regular client, I agree to give you one month’s notice of any increase in fees or cancelation of services.
For every referral that comes in for an appointment, I will give %10 off your next massage.
Confidential Health History Form
Date: Date of birth:
Phone: Best way to reach you:
Alternative Practitioner or Physician:
- Reason for coming in today:
- Possible causes:
- List any acute (new pain occurring within the last 3 months) and/or any chronic pain (lasting over 3 months) that you are experiencing?
- Previous accidents or injuries:
- List any treatments you have received over the last 3 years.
- Are you currently taking any form of medication?
Circle any current conditions; underline any you have had in the past.
skin disorders headaches joint pain
numbness/tingling varicose veins eye pain
joint swelling cold hands/feet blood clots
head injury arthritis sinus problems
deep leg pain vision problems neuralgia (nerve pain)
high/low blood glasses muscular pain, or cramping
pressure glaucoma broken bones
cancer/treatment dizziness muscle weakness, fatigue
surgery ringing in ears scoliosis
Breathing patterns: circle or place X next to your experiences.
Chemical exposure Asthma
Shortness of breath Upper respiratory infections
Difficulty concentrating Bronchitis
Heart palpitations Allergies
Anxiety/fear Gastrointestinal issues
- How much (in oz.) water do you drink per day?
- Coffee/tea? Soda? Alcohol (per week)?
- What is the source (tap, bottled, filtered and type) of your water intake?
- Do you have (circle): dry mouth, dry skin, chapped lips, hangnails, rashes, skin allergies, constipation, decreased urination, dizziness?
- Do you know your blood type? O A B AB
Diet: please list a percentage of your total daily intake.
- Processed foods
- Dining out
Please circle any that pertain to you: Belching or gas, gall bladder or liver problems, heartburn,
indigestion, vomiting, undigested food or blood in stool, change in appetite or thirst, jaundice,
binge eating, abdominal cramping, kidney stones, incontinence, night frequency,
constipation/diarrhea, hemorrhoids, frequent or painful urination, bladder infections, cloudy or
What is your frequency of bowel movements X/day.
Movement: If 24 hours is 100%...
- What % do you spend sitting, driving, reclining, laying down, sleeping?
- What % do you spend walking, exercising, stretching, performing activities of daily living?
- Is your job active? If not, how long do you sit at your job without getting up and moving around?
- Describe your stretching and exercise habits.
- What do you do to relax? Do you feel relaxed throughout your day?
- Do you meditate, pray, go to church or a gathering? Describe your spiritual practices and how often you practice.
- What do you say to yourself? Kind, loving words? Or negative, critical words?