Consent Forms

Pediatric Client Intake Form

Child’s Name __________________________________ Birthdate ______________ Age ________

Parent(s) Name(s) ____________________________ Home Phone ________________________

Work Phone ________________________ Cell Phone __________________________________

Street ___________________________ City__________________ State _______ Zip _________

Parent Occupation/Employer ________________________________________________________

Please mark your goals for your child’s Pediatric Massage Program:



Provide Comfort



Improve pulmonary functions



Promote relaxation



Decrease symptoms of atopic dermatitis



Reduce stress



Reduce lethargy



Reduce pain



Reduce colic / chronic abdominal pain



Ease Depression



Promote growth for baby born prematurely/child



Decrease anxiety



Improve self-soothing behavior



Reduce muscle hyper tonicity



Improve attentiveness and responsiveness



Improve muscle tone (decrease hypo tonicity)



Improve sleep patterns



Improve gastrointestinal functioning



Decrease hypersensitivity to touch



Improve joint mobility / range of motion



Encourage vocalization



Promote orientation of extremities toward midline



Enhance child’s body awareness



Reduce chronic fatigue



Promote parent-child bonding

Other Goals: ______________________________________________________________________


Health History

Birth History:  Biological Child  Adopted  Foster Child

Weeks gestation: _________ Delivery:  Vaginal Forceps  C-Section  Vacuum Extraction

Postpartum complications?  No  Yes (describe): _____________________________________

Is your child currently under the care of a primary healthcare provider?  Yes  No

Name of healthcare provider:__________________________________________________________


Name of healthcare facility: ___________________________________________________________

Location: ____________________________________________ Phone: ______________________

May I exchange information when necessary with this provider?  Yes  No


My child is developing:

 like an average child for his/her age in all areas of development

 differently than an average child his/her age in any area of development.

Describe: ________________________________________________________________________

Please list medications, supplements or homeopathics the child is now taking:

Medication/Herb/etc.ReasonStartedDosage





Please mark any of the following that your child now has or has had in the past. Identify the condition and location where applicable.

Now

Past

Condition

Now

Past

Condition





Skin Conditions

(includes rashes, topical allergies, fungal infections, etc.)


Type ______________________

Location ____________________





Respiratory Conditions

(includes sinus, lung and bronchial conditions, etc.)

Type ______________________

Location ____________________





Muscle Conditions

(includes strains, tendonitis, spasms, cramps)

Type ______________________

Location ____________________





Circulatory Conditions

(includes heart, blood pressure, arteries and venous conditions, etc.)

Type ______________________

Location ____________________





Joint Conditions

(includes sprain, arthritis, degenerating joints)

Type ______________________

Location ____________________





Reproductive Conditions

(includes pregnancy, prostate, menstruation)

Type ______________________

Location ____________________





Nervous System Conditions

(includes numbness, tingling, nerve damage, shingles, etc.)

Type ______________________

Location ____________________





Digestive Conditions

(includes constipation, diarrhea, ulcers)

Type ______________________

Location ____________________





Infectious or Communicable Conditions

Type ______________________

Location ____________________





Other Conditions

(includes any other health condition not previously listed)

Type ______________________

Location ____________________

Other medical conditions, symptoms and/or further explanations: ____________________________

_________________________________________________________________________________

Please list any recent accidents, illnesses or surgeries (past 2 years -- or those that are still affecting your child): ________________________________________________________________________________

_________________________________________________________________________________

Please list any special dietary/nutritional considerations: (ie: gluten-free diet, allergies)

_________________________________________________________________________________

How do these symptoms affect the child’s daily life? _________________________________________________________________________________

Therapeutic History

Has you child ever received massage or another bodywork therapy (professionally or by a parent’s touch)? (example: yoga therapy, cranial sacral therapy, bioaquatic therapy)  Yes  No

If yes, please explain: _________________________________________________________________________________

_________________________________________________________________________________


Please list other complementary therapies or educational programs in which your child participates:

Therapy/ProgramReasonStartedPractitioner







May I exchange information when necessary with these providers?  Yes  No

Has your child been evaluated for or diagnosed with Sensory Integration Disorder?  Yes  No

If yes, please explain evaluation, diagnosis and/or therapy program: 

_________________________________________________________________________________





Never

Some

Often

Always

In the past

This is a problem

dislike being held or cuddled?

seem irritated when touched?

bang or hit head on purpose?

seem overly aware of touch, texture or temperature?

have an increased response to pain?

Lack awareness of being touched?

bite, chew or suck on blanket/pacifier/something to calm?

frequently bump into or push people or items?

have a strong need to touch objects and people?

try to bite people?

dislike being bounced, rocked or swung?

seek out rough-housing play?

have fear in space (i.e. on stairs, heights, etc.)?

dislike being off balance?

How does your child respond to touch/movement? Does your child:

Personal History

Please describe your child’s communication style:

 Verbal  Word Approximations  ASL  PECS  Augmentative Device  Gestures  None

Other: ________________________________________________________________________________

How does your child deal with change? ________________________________________________________________________________

What types of methods does your child use to manage stressful situations (self-soothing techniques)?

_________________________________________________________________________________

________________________________________________________________________________

What makes your child: (And, how do you deal with it)

Happy?

Sad?

Angry?

Stressed?

Excited?

Does your child attend school/preschool/daycare?  Yes  No

If yes, what are his/her teacher’s name(s)? _____________________________________________

What are the names/types of his/her pets? ______________________________________________


What are the names of his/her siblings? _________________________________________________

What are the names of his/her friends? _________________________________________________

What types of exercise interests your child? _____________________________________________

How does your child prefer to spend his/her time (hobbies/interests)? _________________________

_________________________________________________________________________________

I have listed all my child’s known medical conditions and physical limitations and will inform the massage therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must be aware of any and all existing physical conditions that my child has in order to provide appropriate massage. I further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorder, nor performs any thrusting joint or spinal manipulations or adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my child may have.


I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being charged.

Signed ________________________________________________ Date ____________________

Parent/Legal Guardian of ___________________________________________________________