Client Health History
 

Name: ______________________ DOB: ___/___/___ Occupation: ___________________

Occupation Duties:__________________________________________________________

Address: ____________________  City: ______________ St/Zip: ____________________

Email: ______________________  Phone: _____________Cell: ______________________

Emergency Contact: __________________________ Phone: _________________________

Have you ever received a professional massage before:               Yes / No

List any chief complaints, pain or areas of discomfort: _______________________________

List wellness activities (e.g., fitness, nutrition, meditation, spiritual study, self-growth study, dental   
hygiene, detoxification practices) ________________________________________________

_________________________________________________________________________                               

_________________________________________________________________________

Medical Practictioners you are presently seeing:

Name: _______________________ phone: _______________ reason: ________

Name: _______________________ phone: _______________ reason: ________

Current medications:

_____________________  for: ______________________ dosage: __________

_____________________  for: ______________________ dosage: __________

Surgeries within the past 15 years:

_____________________ date: ___/___/___ reason: _____________________

_____________________ date: ___/___/___ reason: _____________________

Accidents within the past 15 years:

_____________________ date: ___/___/___ injuries: _____________________

_____________________ date: ___/___/___ injuries: _____________________

List ALL health conditions that you have had in the past and/or presently have:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
 

I understand that  massage therapists do not diagnosis illness, disease, or any physical  or mental
disorder, or prescribemedical  treatment,  pharmaceuticals, or  perform spinal  trust manipulations.  
I  acknowledge  that massage  is not  a substitute for  medical  examination or diagnosis, and that it
is recommended that I see a physician or medical specialist for that service. I have stated all medical
conditions that I am aware of and will  update the therapist of any  changes in my health.

CLIENT SIGNATURE: ________________________________________  DATE: ___/___/___

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