Massage Client Health History Form
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2Massage Client Health History Form
Client Information and Release Form
Name ____________________________________________________ Birth Date ____________________
Address ________________________________________________________________________________
City __________________________________________ State ________ Zip ________________________
Phone Number(s) ___________________ Home __________________ Work __________________ Cell
E-mail Address__________________________________________________________________________
Referred By ________________________Is this your first massage?________________________________
General Medical History
Check the box if you have or have had recent problems with any of the following:
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Arthritis
High Blood Pressure
Sinus / Allergies
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Bursitis
Low Blood Pressure
Hematomas
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Back Pain
Poor Circulation
Phlebitis
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Neck Pain
Anemia
Vericose Veins
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Arms / Hands (Pain)
Stroke
Cancer
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Hips / Legs / Feet (Pain)
Chest Pain
Skin Conditions
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Headaches
Seizures / Convulsions
Pregnant? ____# of months
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Swollen Joints
Heart Conditions
Menstrual Pain
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Fibromyalgia
Constipation
Warts
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Athlete’s Feet
Please circle any areas of pain, injury, tension, or restriction of movement.
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Parent category: Medical