Bodymind Wellness - Massage Therapy and Bodywork
                   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 _____________________________________________
Smoker?   Yes  ____   No _____

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.  

Please note:  24 hours is expected and appreciated in the event of a cancellation.  Emergencies are accepted for the first cancellation without 24 hrs notice.  Otherwise, regular session fee is due.
 
Signature: ______________________________________    

Date: ___________
 
 
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