Assessment First Remedial Massage Therapy Client Information And Consent Form printable pdf download

Assessment First Remedial Massage Therapy Client Information And Consent Form

ASSESSMENT FIRST REMEDIAL MASSAGE THERAPY - Marie Trafford, RMT

CLIENT INFORMATION AND CONSENT FORM

FYI: an accurate health history ensures that it is safe for you to receive a massage treatment, and

helps the therapist determine a proper treatment plan. When your health status changes in the

future, please let us know. All information gathered on this form is confidential. Your written

authorization is legally required before any of this information can be released.

Name: __________________________________________________________________________

Address: _______________________________________________________________________

_____________________________________________Postal Code ________________________

Today’s date: ______________________________ Date of Birth: __________________________

Phone Numbers: Home: ________________ Cell: ________________ Work: ________________

Email Address: __________________________________________________________________

Occupation: _____________________________________________________________________

How did you hear about us? _________________________________________________________

Physician’s name/Phone number & address (if you know it) ________________________________

_______________________________________________________________________________

What is your major area of concern that you would like treated? (Write below & circle the areas)

_______________________________________________________________________________

On the body diagrams to the left, please circle

the areas that you are experiencing

problems/pain/stiffness etc. If you are

experiencing pain in one area and feeling it

elsewhere, please indicate this with arrows.

Assessment First Remedial Massage Therapy Client Information And Consent Form