City ________________________ ST _____ Zip ___________
Birth Date _______________________
Telephone # _____________________
Business # ______________________
Have you received Massage Therapy or Bodywork before? _________ What Kinds? ____________
Please check off any of the following conditions or symptoms which apply to you now or in the past:
____High Blood Pressure
____Low Back Pain
____Allergy to Nut Oils
____Low Blood Pressure
____Hypo or Hyperglycemia
____Muscle Sprain / Strain
____Heart Attack / Stroke
Please list and explain other conditions/symptoms you are or have experienced: __________
Have you had any serious or chronic illness, operations, or traumatic accidents? _______
If yes, please explain: ___________________________________________________________
Are you currently, or have you at any time within the last 12 months been under the care of a physician? _____
If so, for what condition?________________________________________________
Are you on any medication? _______ If yes, which ones? ________________________________
May I have permission to contact your Doctor / Therapist? ________
Doctor / Therapist Name: ______________________________ Telephone __________________
Do you exercise? _____ How many times per week? _____ For how long? __________________
What percentages of the foods you eat would you say are:
Grains _______ Fruits ______ Meats ______ Fish ______ Dairy ______ Vegetables ______ Desserts/Sugar ____ Junk Foods ____
How many ounces of water do you drink per day? ___________________________
Do you drink caffeinated beverages? _______ If so, how many bottles/cups per day of the following? Soda Pop______ Coffee________ Black Teas_________
Do you smoke cigarettes? _________ How many per day? __________
Do you consume alcohol? _________ How many drinks per: Day _____ Week _____
I have completed this health form to the best of my knowledge. I understand that Massage Therapy and Bodywork services are a therapeutic health aid and are non-sexual. They do not take the place of a physician’s care when indicated. Any information exchanged during a Massage or Bodywork session is confidential and is only used to provide you with the best health care services.
If I am not able to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case, I will call ASAP to reschedule my appointment.
If I miss a scheduled appointment without giving 24 notice, I agree pay any missed appointment charge applicable.
I am responsible to pay for any Massage or Bodywork fees not paid for by my insurance company.
Name (signature) _________________________________________ Date _____________________