Client History Template printable pdf download

CLIENT HISTORY

Name:_________________________________________

Date: _________________

Address: ______________________________________

Phone: _________________

______________________________________

DOB: __________________

Email: ____________________________________________________

Occupation: ____________________________________

Emergency Name & Number: ______________________________

How did you hear about us? ___________________________________________________________________________________

Have you ever experienced a professional massage or bodywork session? _____________________________________________

Primary reason for appointment? ______________________________________________________________________________

Please take a moment to carefully read and mark the following information as it applies to you. If you have specific medical

conditions or symptoms, massage /bodywork may be contraindicated. A referral from your primary care provider may be

required prior to service being provided.

___ Headaches/Migraines

___Tension/Stress

___Fatigue

___ Chronic Pain

___ Joint Pain

___Muscle or Bone Injuries

___Rotator Cuff Injury

___Arthritis

___Numbness or Tingling

___Trouble Sleeping

___Jaw Pain, TMJ

___Chronic Sinus Issues

___Allergy/Sensitivity

___Rashes, Athletes Foot

___Infectious Disease

___Blood Clots/Phlebitis

___Spinal Column Disorders

___Asthma, Lung Conditions

___Circulatory Problems

___Heart Attack

___Digestive Problems/Disorders

___ Hernia

___Lupus

___ High Blood Pressure

___Mental Illness

___Heart Conditions

___Fibromyalgia

___Wearing Contacts

___Wearing Dentures

___Grieving

___Bruise Easily

___Epilepsy/Seizure

___ Injuries/ Surgeries

___Diabetes Type __1__2

___Other medical conditions we should be aware of?

If you checked any of the above, please briefly explain. We will discuss them before your massage.

________________________________________________________________________________________________________________

Explain Condition/s not listed: _________________________________________________________________________________

________________________________________________________________________________________________________________

Current Medications (ie. Blood thinners, pain killers, anti-depressants):

No. of hours on computer /day _______________

Activities that aggravate your pain:_________________________________________________________________________________

___________________________________________________________________________________________________________

Have you ever had cancer ?

[ YES ]

[ NO ]

Type:_____________________________________________________________

Date diagnosed: _____________

Time Recovered: _______________

WBC (4.5-10): _________ PLT (150-450): ___________

Treatment/s:___________________________________________________________________________________________________

Were any lymph nodes removed/irradiated? [YES ] [NO ] If yes, Neck [ ] Armpit [ ] Groin [ ]

Client History Template

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