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about
information
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Confidential Client Information and Health History
PERSONAL DATA
*
Indicates required field
Name
*
First
Last
Height
*
Weight
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date
*
Date of Birth
*
Email
*
Cell
*
Work
*
Home
*
Preferred contact method
*
Email
Cell Phone
Home Phone
Work Phone
Text
Occupation
*
Referred By
*
Emergency Contact
*
Relation
*
Emergency Contact #
*
MASSAGE HISTORY / TREATMENT INFORMATION
Have you had a professional massage?
*
Yes
No
Have you ever received a professional massage?
If yes, frequency
*
How often do you receive massage?
Date of last massage
*
Purpose of treatment?
*
What goals do you have with receiving massage (e.g. relaxation, stress relief, pain relief, etc.)
Any other comments or concerns about treatment?
*
Are you currently seeing a medical practitioner
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Yes
No
If yes, explain
*
List stress reduction and exercise activities. Include frequency
*
List current medications, including aspirin, ibuprofen, etc.
*
MEDICAL HISTORY
(include year and treatment received)
Surgeries
*
Accidents
*
Health History
(check all that apply)
MUSCULOSKELETAL
*
bone or joint disease
tendonitis
bursitis
broken/fractured bones
arthritis
neck, shoulder, arm pain
low back, hip, leg pain
headaches/ head injuries
spasms / cramps
jaw pain / TMJ disfunction
sprains / strains
other
CIRCULATORY
*
heart condition
varicose veins
blood clots
high blood pressure
low blood pressure
lymphedema
breathing difficulty
sinus problems
allergies
other
comments: musculoskeletal
*
comments: circulatory
*
SKIN
*
allergies
rashes
athletes foot
warts
other
NERVOUS SYSTEM
*
herpes/shingles
numbness/tingling
chronic pain
fatigue
sleep disorders
other
comments: skin
*
comments: nervous system
*
DIGESTIVE SYSTEM
*
constipation
gas / bloating
diverticulitis
IBS
other
REPRODUCTIVE
*
pregnant? Stage
PMS
other
comments: digestive
*
comments: reproductive
*
INFECTIOUS DISEASE
comments: infectious disease
*
OTHER
*
cancer / tumors
diabetes
eating disorders
depression
drug / alcohol addiction
nicotine / caffeine addiction
other
Anything else you wish to include?
*
comments: other
*
The above information is accurate and true to the best of my knowledge. It is my choice to receive massage therapy. 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 massage therapist any time I feel my well-being is being compromised.
I understand that massage therapists do not diagnose illness, disease, or any physical or mental disorders, 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.
Because massage/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 health status and understand that there shall be no liability on the practitioner’s
part if I fail to do so. I also understand 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 full payment of the scheduled appointment.
Name
*
First
Last
Date
*
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