Body Therapy Center Student Massage Clinic Confidential Client Information Form printable pdf download

Body Therapy Center Student Massage Clinic

Confidential Client Information Form

Patient Information

Name:

Today’s Date:

Address:

City, State, Zip:

Home Phone:

Work/Cell Phone:

Occupation:

Date of Birth:

Emergency Contact:

Emergency Contact Phone:

Would you like to be on our emailing list?

If yes, list your email address:

□ Yes □ No

Are you currently under a physician’s care for an acute or chronic illness? □ Yes □ No

If yes, please explain:___________________________________________________

Are you currently taking any prescribed medication/supplement? □ Yes □ No

If yes, please explain:___________________________________________________

Are you currently experiencing stress in your work or personal life? □ Yes □ No

If yes, please explain:___________________________________________________

Have there been any significant changes in your life recently? □ Yes □ No

If yes, please explain:___________________________________________________

Have you consumed alcohol in the last 24 hours? □ Yes □ No

Do you have a fever? □ Yes □ No

Are you under 18 years of age? □ Yes □ No

If yes, parental consent must be obtained on this form prior to session.

Are you pregnant or think you may be pregnant? □ Yes □ No

If yes, what trimester_______ and your due date_______

Have you had surgery or been involved in an accident in the last 24 months? □ Yes □ No

If yes, please list:___________________________________________________

Session Information

Have you had a massage before? □ Yes □ No

If yes, when:____________________

What are your goals for this session?__________________________________________

What type of touch do you prefer?

□ Light/Meditative

□ Heavy/Invigorating

□ Deep/Trigger Point

Do you have difficulty lying on your front, back, or side? □ Yes □ No

If yes, please explain:___________________________________________________

Do you have allergic reactions to oils, lotions, ointments, liniments, or other substances put on your skin? □ Yes □ No

If yes, please explain:___________________________________________________

Please list areas of tension, stress, and/or pain you wished to be addressed:_____________________________________

_________________________________________________________________________________________________

Please list any area(s) you DO NOT want the therapist to massage: ___________________________________________

_________________________________________________________________________________________________

Body Therapy Center Student Massage Clinic Confidential Client Information Form

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