Date:

Client Name:*

Date of Birth:*

Address:

Phone:*

Email:*

Referred by:

Have you had any injuries or surgeries in the past that may influence bodywork treatment?

Do these symptoms interfere with your daily living activities? ( e.g., sleep, exercise, work, childcare)?

How would you rate your overall health?

List current medications and the conditions they're treating*

Are you wearing contacts?

Are you wearing dentures?

Do you bruise easily? *

Are you pregnant?*

If yes, how far along are you?

Is your pregnancy high risk?

Please list any allergies or hypersensitives:

Have you ever received professional massage/bodywork before?

What types of massage/bodywork do you prefer?

What kind of pressure do you prefer?

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?

What are your goals/expected outcomes for receiving massage/bodywork?*

Please check areas you give consent to have worked during your bodywork session:

Head/Neck:*

Respiratory: *

Musculoskeletal System: *

Cardiovascular: *

Nervous System: *

Skin Infections:*

Other conditions:*

Any other condition your practitioner should be aware of ?*

The above information is accurate to the best of my knowledge. It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. (Sign)*

I understand that no inappropriate comments or conduct will be tolerated. Any indication of such will terminate the session and result in a full charge of the service. (Sign name below)*

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. (Sign name below)*

I acknowledge that massage therapy is not a substitute for medical care, medical examination, or diagnosis. (Sign name below) *

Write your full name below for signature*

Emergency Contact Name:

Emergency Contact Phone:

Comments:

Please list your favorite genre of music you enjoy for relaxation