Name: ___________________________________________________________ Date: __________________

Address: _________________________________________________________________________________

Birthday: ______________________ Occupation: _______________________________________________

Phone Number: _____________________ Email: _______________________________________________

Emergency Contact (name and phone): ______________________________________________________

Would you like to receive emails letting you know of promotions or changes? Y / N

Allergies? __________________ Prescription Medications? ______________________________________

Surgeries/Falls/ Accidents (last 5 years)? _____________________________________________________

_________________________________________________________________________________________

Are you being treated by other Healthcare Professionals? ______________________________________

Medical Implants/Wires? ___________________________________________________________________

Diagnoses/Illnesses/Concerns? _____________________________________________________________

Overall, how do you feel about your health? __________________________________________________

What pressure do you prefer for your massage? Lighter Medium Firm

Please circle any areas of discomfort, and elaborate below if

need: ____________________________________________________

Please check conditions you have had or are currently experiencing, as well as make a note of

anything else relevant to your health that you should disclose before beginning massage therapy.

Women: Are you currently pregnant? When are you due: ______________________________________

Are you experiencing any difficulty during this pregnancy? ______________________________________

Have you had prenatal massages before? ____________________________________________________

I have informed the massage therapist of all my known conditions and medications. I will continue to

update any changes in my health history. I understand that:

• I may ask questions about anything at anytime.

• All client information is confidential and written authorization must be obtained to release any

information to other caregivers

• Any contraindications to massage therapy that are relevant to me

• I understand the assessment and treatment to be preformed and that draping will only expose

areas requiring treatment

• That at anytime I can withdraw my consent and treatment will be stopped without a question

• The duration and cost of the massage therapy treatment

• That massage therapy is not a substitute foe medical treatment or medications

• That it is recommended that I work with my primary caregiver for any condition I may have

• That a massage therapist will not diagnose illness or disease and will not prescribe medication

Signature: ______________________________

Date: __________________________________

High Blood Pressure Emphysema Shortness of Breath

Varicose Veins/Phlebitis Chronic Congestive Heart Troubled Skin

Low Blood Pressure Pacemaker Asthma

Stroke / CVA Heart Disease Headaches / Migraine

Chronic Cough Bronchitis Mental Illness

Arthritis Loss of sensation Epilepsy

Diabetes Ear troubles / loss HIV/Aids