Massage Client Health History Form (Page 2 of 2) in pdf

Have you recently suffered an acute injury? _____________________________________________

Have you had any recent surgery? ____________________________________________________

Do you have any other medical conditions that I should be aware of? _________________________

Where do you carry your stress and tension? ____________________________________________

Do you wear contacts? _____________________________________________________________

Do you have any problem areas / injuries? ______________________________________________

Do you take any prescription medications? ______________________________________________

Do you have any allergies? Yes or No, and if yes what are you allergic to? _____________________

Describe exercise activities that you do. Include Frequency. ________________________________

Are you very sensitive to touch / pressure in any areas? ____________________________________

What type of pressure do you like? ____________________________________________________

What is your goal in the session today? _________________________________________________

Please list any additional comments regarding your health and well being if needed. _____________

________________________________________________________________________________

Your answers to these questions will be discussed with you prior to your session. Thank You.

Please take a moment to carefully read the following information and sign where indicated.

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction, and

relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform

the practitioner so that the pressure and / or strokes may be adjusted to my level of comfort.

I further understand that massage should not be considered as a substitute for medical examination, diagnosis,

or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental

or physical ailment that I am aware of.

I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis,

prescribe, or treat any physical or mental illness, and that nothing said in the course of the session(s) given

should be considered as such. Further, no comments or gestures that are sexual in nature will be tolerated by

the massage therapist. In the event that I violate this policy, my session will be immediately terminated.

Because massage is contraindicated under certain medical conditions, I affirm that I have stated all my known

medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any

changes in my medical profile, and understand that there shall not be liability on the practitioner’s part should I

forget to do so.

Signature______________________________________________________Date _____________________

Consent for minors is required prior to treatment.

Signature of Guardian____________________________________________ Date _____________________

Printed name of Guardian __________________________________________________________________

Phone number the Guardian can be reached in case of emergency __________________________________

Massage Client Health History Form Page 2