CLIENT INFORMATION FORM

NAME: _______________________________________________ DATE: _________

ADDRESS: ___________________ CITY: ____________ STATE: ___ ZIP: ______

HOME PHONE: __________________ SECONDARY PHONE: ________________

DATE OF BIRTH: _____________ AGE: ____ GENDER (PLEASE CIRCLE): M/F

OCCUPATION: ________________________ REFERRED BY: _________________

PHYSICIAN: ____________________ MEDICATIONS: _______________________

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EMERGENCY CONTACT: _______________________________________________

HAVE YOU EVER RECEIVED MASSAGE THERAPY? YES/NO

IF YES WHAT TYPES OF MASSAGE HAVE YOU EXPERIENCED? __________

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PLEASE CHECK ANY OF THE FOLLOWING WHICH APPLY TO YOUR PRESENT

OR RECENT HEALTH:

( ) FEVER ( ) HEART TROUBLE

( ) INFECTION/ILLNESS ( ) HIGH BLOOD PRESSURE
( ) PREGNANT ( ) SKIN PROBLEMS
( ) DIABETES ( ) HIV OR AIDS POSITIVE
( ) SURGERY ( ) CANCER
( ) INJURIES ( ) CHRONIC AILMENTS
( ) BACK PAIN ( ) MUSCLE CRAMPS
( ) STIFF JOINTS ( ) SCIATICA
( ) STIFF NECK ( ) INFLAMMATION
( ) ARTHRITIS ( ) CUTS/BURNS/BRUISES
( ) HEADACHES/MIGRAINES ( ) SEVERE PAIN
( ) POISON IVY ( ) SUNBURN

DO YOU HAVE ANY ALLERGIES? (ESPECIALLY TO NUT, FRUIT, PLANT, OR

TREE OILS): __________________________________________________________
DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING?

( ) ACCIDENT ( ) SPRAINS ( ) FIBROMYALGIA

( ) NECK PAIN ( ) SEIZURES ( ) BREAST AUGMENTATION
( ) WHIPLASH ( ) ABDOMINAL PAIN ( ) DIABETES
( ) HEADACHES ( ) NERVOUS TENSION ( ) VARICOSE VEINS

( ) DISK PROBLEMS ( ) ARTHRITIS ( ) HIGH BLOOD PRESSURE

( ) MID BACK PAIN ( ) LOW BACK PAIN ( ) STROKE
( ) JOINT ACHE ( )HEART ATTACK ( ) CANCER
( ) COLITIS ( ) SURGERY ( ) PROSTHETIC LIMB

( ) OTHER __________________________________________________________

PLEASE INDICATE YOUR INTAKE LEVELS OF THE FOLLOWING:

NONE LIGHT MODERATE HEAVY

SALT () () () ()
SUGAR () () () ()
CAFFEINE () () () ()
TOBACCO () () () ()
ALCOHOL () () () ()
EXERCISE () () () ()
WATER () () () ()

PLEASE CIRCLE ANY PLACES IN THE DIAGRAM WHERE YOU ARE

EXPERIENCING PAIN OR DISCOMFORT:
PLEASE READ THE FOLLOWING STATEMENTS AND SIGN BELOW:

I understand that massage therapists do not diagnose illness, disease, or any other form of
physical and mental disorder. I understand that massage therapists do not prescribe
medical treatments or pharmaceuticals, nor do they perform spinal manipulation.

Massage therapy is not meant to be, nor is it a substitute for medical care, examination, or
diagnosis. I understand that the therapist may recommend that I see a physician for any
physical ailment I might have.

I am aware that setting an appointment with a massage therapist is a contract for a block
of her time, and that I will be responsible for payment in full for an appointment not
attended if I do not provide a 24 hour notice.

DATE: _____________ SIGNATURE: ___________________________________

PLEASE READ AND SIGN THE FOLLOWING IF YOU WILL BE PAYING BY

CHECK:

I understand that I am responsible for payment in full for my appointment with the
massage therapist. I am aware that my check payment will be accepted in good faith by
the massage therapist, and if the check is returned as cancelled, or non sufficient funds I
understand that I will be responsible for making an additional payment of $30.00 in
addition to the cost of my appointment.

DATE: ____________ SIGNATURE: _____________________________________