Massage Therapy Client Information

Name:____________________________Telephone:________________Date of Birth: _________________

Address: _____________________________________________________________________________

_________________________________________________________________________________________

In case of emergency:_________________________________Telephone: _____________________________

Please check all of the following conditions that apply and explain:

____ Allergies ______________________ ____ Fatigue ____ Sensitive to touch

____ Arthritis ____ Fibromyalgia ____ Sinusitis

____ Back Pain ____ Headaches ____ Skin Disorders

____ Blood Clots ____ Heart Condition ____ Stomach Disorders

____ Bursitis ____ Hepatitis ____ Stress

____ Circulatory Problems ____ Herniated Disc ____ Tension or Soreness

____ Constipation ____ High Blood Pressure ____ TMJ Dysfunction

____ Contact Lenses ____ HIV ____ Varicose Veins

____ Diabetes ____ Numbness/Stabbing Pain ____ Other-Describe Below

____ Diarrhea ____ Pregnant

Medical conditions not listed above: __________________________________________________________

________________________________________________________________________________________

Current Medications: ______________________________________________________________________

________________________________________________________________________________________

Surgeries: ____________________________________________________________________________

referral from your primary care provider may be required prior to service being provided.

Because a massage therapist must be aware of any existing physical conditions that I may have, I have listed all

my known medical conditions and physical limitations and I will inform my massage therapist of any changes in my

physical health.

I understand and agree that: (1) the massage therapy that I am given is for the purpose of stress reduction, relief

from muscular tension or spasm and/or for improving circulation; (2) that a massage therapist neither diagnoses illness,

disease or any other medical, physical or mental disorder, nor performs any spinal manipulations; (3) I am responsible for

consulting a qualified physician for any physical ailments that I may have; (4) that health and accident insurance policies

are an arrangement between an insurance company and myself, and that this office will help prepare any necessary reports

to assist me in making collection from the insurance company.

I agree that all services rendered to me are charged directly to me and I am responsible for payment unless prior

arrangements have been made. I agree to pay for all scheduled appointments that I am unable to keep unless I notify

my therapist at least 24-hours in advance.

Signature_____________________________________________Date_____________________