Client Health History Form
Please print, complete and bring with you
the day of your appointment.
Date _____________ Referred by _________________
Name_____________________________ Cell Phone _________________
Address (street) ______________________ Home Phone ________________
(town)_____________________________ Work Phone ________________
(state, zip) _____________________________ Date of Birth ___/___/_____
Email Address __________________________________(no spam, promise)
Occupation ______________________________________________________
Exercise / Sports Activities _____________________________________________
Have you ever received a Therapeutic Massage? Yes__________ No_________
Was it intended for stress relief & relaxation? ____ For pain relief? ____ Both? ____
Reason for today’s visit ______________________________________________
List any accidents, fractures, and surgeries in the past 5 years:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
List any accidents, fractures and surgeries beyond 5 years ago:
_________________________________________________________________
Describe any current or ongoing muscular-skeletal pain or stiffness:
Please list current medications you are taking: ______________________________
________________________________________________________________
Are you allergic to aspirin? ___________
Allergies or sensitivity to oils, lotions, scents? NO ___YES (please list) __________
__________________________________________________________________
Are you Pregnant? _____ If so, how far along _____________________________
I am sensitive / ticklish on my feet ______ I am ticklish (other)__________________
Existing Conditions – Please check any/all that apply now –
or place a “P” for conditions experienced in the past.
Varicose Veins _____ Blood Clots ______ Swollen extremities ____
Numbness / Tingling ____ Herniated Disc ___ Sciatica _______
Scoliosis _______ Osteoporosis ______ Muscle Tightness______
Infectious Disease _____ Depression _____ Bowel Irregularities ____
Muscle, bone injuries ___ Muscle, joint injuries ___ TMJ, jaw pain _____
Headaches ____ Migraines ____ Neck Pain ____ Dizziness / fainting __
Loss of Balance ____ Inner Ear problem _____ Allergies _____
Sinus pain/infection _____ Asthma ____ Thyroid Imbalances ____
Hypoglycemia ______ Diabetes _______ Cancer / Tumors ______
Respiratory problem ____ Seizures/convulsions ____
Immune Deficiency _____ Skin Sensitivity ______Low Blood Pressure ____
Liver Problem _____ Kidney Problem _____High Blood Pressure ____
Gall Bladder Problem __ Easy Bruising ___ Sleep Irreg.___ Joint Pain ___
Bladder Problems ____ Digestive Problems ____ Hepatitis ___ Herpes ___
Chronic Fatigue ___ Chronic Stress ___ Fibromyalgia___ Lyme Disease ___
OTHER MEDICAL CONDITION NOT LISTED ________________________________________________________
Please explain any areas noted above if you are currently seeing a doctor for that condition:
______________________________________
The Information shared on this form and in session is treated with confidentiality.
Please give feedback at any time during or after the massage. This communication between you and I during the massage will facilitate a more productive outcome from
the session for you.
I, the client, understand that the work done during this massage does not constitute medical treatment and that the massage therapist is not a physician. The session is a
form of health and wellness maintenance utilizing the techniques of massage and
holistic healing. I, the client, take responsibility for alerting the therapist to any
conditions that might affect this work. It is recommended that I, the client, see a
physician for any ailments I might have. Any suggestions made by the massage
therapist are recommendations, not prescriptions. I understand and agree to the above conditions.
Signature: ______________________________________
Date: ___________
