Client Information and Health Questionnaire
Name: _______________________________________ Address: _____________________________________________
City: _______________________ Zip Code: ____________ Age: ______ Phone: _______________________
Occupation: _____________________________________________
E-mail: _____________________________ Emergency Contact: ___________________________ Phone: __________________
______________________________________________________________________________________________________
Do you have any of the following pains?
*Headaches/tension *Jaw *Neck *Ankle/Foot *Hip *Shoulder *Pain between the shoulders
*Arm/Wrist/Hand*Knee *Leg *Lower back
Do you have any areas sensitive to touch? __________________________ Have you had any surgeries? _________________
Do you currently take any medications? ________________________
_______________________________________________________________________________
Do you currently have and/or in the past have you had any of the following? Circle any
and ALL that apply
*Kidney/Bladder Issues *Artificial Joint (s) *High Blood Pressure *Diabetes *Hernias
*Epilepsy/Seizures *Contagious Disease *Digestive issues *Cancer *Numbness *Sinus Problems
*Artificial limbs *Hepatitis *Tingling *Inflammatory Disease *HIV/AIDS *Multiple Sclerosis *Aneurysm *Blood Clots
*Fibromyalgea *Heart Disorder (s) *Arthritis *Osteoporosis *Cold Feet/hands
*Skin abnormalities *Artery problem (s) *Respiratory Issues *Varicose veins *Thyroid Hypo/Hyper
*Do you bruise easy? Y/N *Medication: *Allergies:
*OTHER:
___________________________________________________________________________________________________
Please read the following carefully: If you have a specific medical condition or symptoms, massage/body work may be contraindicated, so a
release from your primary care provider may be required prior to services being provided.
I understand that the massage/body work I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I
experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and/or strokes can be
adjusted to my level of comfort. I also understand that massage therapy /bodywork is NOT in any way a substitute for medical examination,
diagnosis, or treatment, And that I should see my physician, chiropractor or other qualified medial specialist for any mental or physical
ailment that I am aware of. Because massage/body work should not be performed under certain medical conditions, I affirm that I have
shared all my known medical conditions, and answered honestly. I agree to keep the practitioner updated as to any changes in my medical
profile and understand that there shall be no liability on the practitioners part should I forget to do so. It is also understood 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 payment of
the scheduled appointment.
My signature confirms that all information on this form is correct:
Client Signature: __________________________________________________________ Date: ________________
Practitioner Signature: ______________________________________________ ______ Date:____________________
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