CLIENT INFORMATION SHEET
Name:__________________________________ HomePhone/ Cell #:____________________
Address: _________________________________ Work Phone: ______________________
City/State/Zip: ____________________________ Birth date: ____________________
Occupation: _______________________ email address: ________________________________
Activities: __________________________
Check all that apply or have applied.
_____Allergies _____Diabetes ____Neck Pain
_____Asthma _____Edema ____Osteoarthritis
_____Back Pain _____Fibromyalgia ___Osteoporosis
_____Blood Clots _____Headaches-reoccurring____Rheumatoid Arthritis
_____Broken Bones _____Heart Condition ____Rotor Cuff
_____Bursitis _____Herniated Disc ____Scoliosis
_____Cancer _____Hypertension ____Sinusitis
_____Carpal Tunnel _____Infectious Disease ____Skin Condition
_____Cold Feet/Hands ____Tendonitis ____Varicose Veins
Other: ___________________________________________
Please note any medications you are currently taking.
____________________________________________________________________________
Please note any serious illness, surgery, accident, injury, etc. that you have had.
Are you under any medical care? _________
If yes, for what condition? _________________________________
What is your Goal for this session? _____Relax
______Treatment, if yes for what? _________________________
In Case of an emergency notify._______________________________________________________
How did you hear of us?
____referred by: ____________________ website:_____ other:__________________
I affirm all the statements noted above are true.It is my responsibility to keep the Therapist updated for any new medical conditions. I understand Massage Therapy is a health aid designed to complement any medical care and in no way takes the place of a doctor's care. I agree to cancel 24 hours in advance and agree to pay for the booked appointment if I don't call or show up on my scheduled time and date.
Signature: ____________________________________________________________Date:_____________________
