Client contact information
Name: _______________________________________ Date: _____________
Date of birth: _________________
Phone: ___________________________ Email: _____________________________
Referred by: _______________________________
Emergency contact: ______________________________________ Phone: __________________
Physician/Health-care provider name: __________________________ Phone: _______________
Is this massage/body work medically necessary (is it for a medical condition, injury, surgery) Yes or No?
What type of massage/body work do you prefer? ____________________ What kind of pressure do
you prefer? Light Medium Firm
What are your goals/expected outcomes for receiving massage/bodywork?
How do you feel today? ____________________________________
List and prioritize your current systoms/ issues (stress, pain, stiffness, numbness/tingling, swelling, etc.)
Do these symptoms interfere with your activities of daily living (sleep, exercise, work, walking etc)? Yes or No Explain:
List any current medications you are currently taking:
Are you pregnant? yes or no
Have you had any injuries or surgeries in the past that may influence today's treatment?
Circle any of the following health conditions that you currently have: blood clots, infections, fever,
congestive heart failure, contagious diseases, pitted edema Please answer honestly, as massage
may not be indicated for the conditions.
Please indicate conditions that you have or had in the past. Explain in detail including treatment
Current or past: Muscle or joint pain or stiffness ________________________________________
Current or past: numbness or tingling __________________________________________
Current or past swelling __________________________________________________
Current or past: bruise easily _______________________________________________
Current or past: sensitivity to touch or pressure ___________________________________
Current or past: high or low blood pressure ______________________________________
Current or past: stroke, heart attack __________________________________________
Current or past: varicose veins _________________________________
Current or past: shortness of breath, asthma _______________________
Current or past: cancer ____________________________________
Current or past: neurological ( e.g. MS, Parkinson's, chronic pain) ________________________
Current or past epilepsy, seizures _____________________________________________
Current or past: headaches, migraines _______________________________________
Current or past: dizziness, ringing in the ears ___________________________________
Current or past: digestive conditions (crohn's, IBS) _____________________________
Current or past: gas, bloating, constipation _________________________
Current or past: kidney disease, infection ___________________
Current or past: arthritis (rheumatoid, osteoarthritis) ___________________________
Current or past: osteoporosis, degenerative spine/disk _____________________
Current or past: scoliosis _____________________________
Current or past broken bones _________________________
Current or past: allergies ___________________________
Current or past: diabetes _________________________
current or past endocrine/thyroid conditions __________________
Current or past: depression, anxiety _________________________
Current or past: memory loss, confusion, easily overwhelmed _______________
Please indicate by circling areas of pain or discomfort:
Consent for Treatment
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so
that the pressure and or strokes may be adjusted to my level of comfort. I further understand that
massage/body work should not be construed as a substitute for medical examination, diagnosis or
treatment and that I should see a physician, chiropractor or other qualified medical specialist for any
mental or physical ailment of which I am aware. I understand that massage/body work practitioners
are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical
or mental illness and that nothing said in the course of the session given should be construed as such.
Because massage/bodywork should not be performed under certain medical conditions, I affirm that
I have stated all my known medical conditions and answered all questions 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 practitioner's part should I fail to do so. I also understand 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. Understanding all of this, I give my
consent to receive care.
Client signature: ____________________________
Please print out, fill out to all areas that apply to you and bring with you at the time of session.
This will save you time of filling out the form and not take away from your session.