Name
E-mail
Address
City
State
Zip
Date of Birth
Home Phone
Cell Phone
How did you hear about me?
Have you received a professional massage before?
Primary reason for appointment
Are you currently taking any pain medication or physician prescribed medications?
If yes, please list below:
Medication:
Prescribed for:
Have you had any major surgeries or injuries that your massage practitioner needs to be aware of?
If yes, please make note of it in the space provided:
Surgery
Date
Injury
Date
Do you have any allergies to lotions, oils, or scents?
If yes, please describe:
If you wear any of the following, please check:
If you have any of the following medical devices, please check:
Below is a list of medical conditions.
Keep in mind that some medical conditions may require you to have a physician’s release form to receive a massage. In some situations massage may not be advisable, but in most cases a session can be modified to suit your needs.
If you are currently dealing with any of the conditions listed below, place a check in the appropriate area.
Blood Heart and Circulatory
Auto Immune, Endocrine and Nervous System
Bone, Joint & Muscle
Chronic Pain
Respiratory
Viral
Cancer
Do you suffer from:
Women Only:
I understand that the massage therapy given is for the purpose of stress reduction, relief from muscular tension, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder.
Client Signature
Date
Client's Health Form
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