Body Therapy Center Student Massage Clinic Confidential Client Information Form Page 2
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1
2Health History
Check the following conditions that apply to you, past and present. Please add your comments to clarify the condition.
Musculo-Skeletal
Skin
Reproductive System
o Headaches
o Rashes
o PMS
o Joint stiffness/swelling
o Allergies
o Menopause
o Spasms/cramps
o Athlete’s Foot
o Pelvic Inflammatory Disease
o Broken/fractured bones
o Warts
o Endometriosis
o Strains/sprains
o Moles
o Hysterectomy
o Back, hip pain
o Acne
o Fertility concerns
o Shoulder, neck, arm, hand pain
o Cosmetic surgery
o Prostate problems
o Leg, foot pain
o Other: ___________________
o Chest, ribs, abdominal pain
Other
o Problems walking
Digestive
o Loss of appetite
o Jaw pain/TMJ
o Nervous stomach
o Forgetfulness
o Tendinitis
o Indigestion
o Confusion
o Bursitis
o Constipation
o Depression
o Arthritis
o Intestinal gas/bloating
o Difficulty concentrating
o Osteoporosis
o Diarrhea
o Drug use _________________
o Scoliosis
o Diverticulitis
o Alcohol use ______________
o Bone or joint disease
o Irritable bowel syndrome
o Nicotine use ______________
o Other: ___________________
o Crohn’s Disease
o Caffeine use ______________
o Colitis
o Hearing impaired
Circulatory and Respiratory
o Other: ___________________
o Visually impaired
o Dizziness
o Bladder infection
o Shortness of breath
o Eating disorder
Nervous System
o Fainting
o Diabetes
o Numbness/tingling
o Cold feet or hands
o HIV/AIDS
o Twitching of face
o Cold sweats
o Fibromyalgia
o Fatigue
o Swollen ankles
o Post/Polio Syndrome
o Chronic pain
o Pressure sores
o Cancer
o Sleep disorders
o Varicose veins
o Physical/Emotional Abuse
o Ulcers
o Blood clots
o Other congenital or acquired
o Paralysis
o Stroke
disabilities (please list) _______
o Herpes/shingles
o Heart condition
__________________________
o Cerebral Palsy
o Allergies
o Infectious disease (please list)
o Epilepsy
o Sinus problems
________________
o Chronic Fatigue Syndrome
o Asthma
o Other: ___________________
o Multiple Sclerosis
o High blood pressure
o Muscular Dystrophy
o Low blood pressure
o Parkinson’s disease
For clients who need mobility assistance,
o Lymphedema
o Spinal cord injury
please give your
o Other: ___________________
o Other: ___________________
height: ________ weight: ________
Please list any additional comments regarding your health and well-being: ______________________________
____________________________________________________________________________________
CONSENT TO PARTICIPATE IN STUDENT MASSAGE: I understand that the student massage clinic exists to provide hands-on
training for massage students of The Body Therapy Center School of Massage, Ltd., and that I have been fully informed that my
participation is voluntary. I have no medical or health conditions which would preclude my participation; that student massage services
are limited in accordance with the school curriculum and not intended to diagnose illness, disease or any other medical or health
disorder; that student massage is not a substitute for an evaluation or a massage from a licensed certified massage therapist; that I agree
to resolve any dispute through arbitration with the American Arbitration Association as my sole legal remedy; that I agree to hold
harmless The Body Therapy Center School of Massage, Ltd., its officers, students, staff or affiliates from any injury arising from my
participation in the student massage clinic and that I have read and fully understand the terms and conditions of the CONSENT TO
PARTICIPATE IN STUDENT MASSAGE and I consent to participate. I understand a clinic supervisor is on-duty and I will direct
any questions or concerns to that supervisor.
Date:___________________
Client’s Signature:_______________________________________
Parent / or Guardian Signature____________________________ Date:___________________
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