This form must be filled out prior to your first massage. I will bring a copy with me for you to fill out if you would like to save time you may print this page and fill it out.
CLIENT HEALTH INFORMATION SHEET
DATE OF BIRTH __________________
REFERRED BY ____________________
PHONE (H) ________________ (W) _______________
EMERGENCY CONTACT __________________________
EMERGENCY # _______________________________
If you are pregnant we need to do an evaluation to determine if you
are eligible for massage at this time.
If you have taken narcotic pain medication or muscle relaxants within
the past 12 hours, you must consult with me prior to massage.
Is this your first massage? Y N
Physical Activities __________________________
What results would you like from your massage:
Decrease muscle stiffness Increase mobility
General wellness Decrease pain/pain management
Other specific physical and/or emotional concerns
Specify and prioritize problem areas to be focuses on _______________________________________
Any body part you do not want worked on _______________________________________
How would you rate your current state of health?
Excellent Good Fair Poor
Are you currently under care of a physician? Y N
If so, for what reason? ____________________________________________________________________
Are you currently taking ANY Medications (please include all)
Y N If so, what medications and for what reasons, _____________________________________________
List any Surgeries
Accidents? <5 yrs ago _____________________________
>5 yrs ago ________________________
What happened in the above accidents _____________________________________________________
Are there any other current or previous health conditions that may be affecting your health or functioning?
Y N If yes, please explain, _____________________________________________________________
IMPORTANT Please indicate if you have any of the following conditions, because, if so, standard massage techniques may not be appropriate.
High blood pressure Osteoporosis Swelling/ Edema
Diabetes Recent injury Chronic Pain Treatment
Fever/Acute infection Undiagnosed Acute Pain
HIV/AIDS/Hepatitis/Infectious Disease Cancer Stroke
Disease of the heart or blood vessels Kidney Disease
Disease of the Nervous System Gastrointestinal or Liver Disease
I understand that a massage therapist does not diagnose, prescribe or treat any specific conditions. I understand that massage therapy is not a substitute for medical examination, diagnosis, and treatment. It is recommended that I see a physician for any ailment I might have. I will update my therapist before any massage if there is change in my medical history. I consent to receive a massage.
Please use the space below for any additional information.