Client Health Questionnaire

Name________________________________________________________ Date_______________________

Phone/Cell_________________________________/_______________________ DOB__________________

Mailing Address___________________________________________________________________________

Occupation_______________________________________________________________________________

Referred By_______________________________________________________________________________

Emergency Contact_______________________________________________________________________

                Health Care Providers_____________________________________________________________

                Alternative Care Providers_________________________________________________________

                Weekend Warrior?___________ If so what Sport/Activity______________________________

                What exercise do you do and how often?___________________________________________

                ___________________________________________________________________________________________

Please list any medications, vitamins or supplements you are taking and what they are for___

___________________________________________________________________________________________

____________________________________________________________________________________________

CIRCLE ALL symptoms or physical problems listed below that you are currently experiencing or

have experienced.

Allergies                          Blood Clots             Bronchitis            Diabetes           Epilepsy                               

Asthma                        Insomnia                Broken Bones         Headaches      Heart Conditions

Kidney Problems        Cancer            Depression        Anxiety    Artificial Joints/pins

High Blood Pressure        Post Traumatic Stress Disorder        Chronic Fatigue

Back Conditions    Other______________________________________________________________________

______________________________________________________________________________________________

Have you experienced any abuse or trauma?__________________________________________________

If so what type of care or treatment did you seek?_____________________________________________

______________________________________________________________________________________________

Have you ever had any other bodywork before? If so for what reason?_________________________

______________________________________________________________________________________________

How would you describe your dietary habits?__________________________________________________

______________________________________________________________________________________________

What do you do to relax or relieve stress or tension?___________________________________________

_______________________________________________________________________________________________

What is your intention for this massage? For example, to relax, stress relief, to ease aches and

pains___________________________________________________________________________________________

________________________________________________________________________________________________

Circle the area, on your body where you have any discomfort, pain or tension. Put the number of

pain or discomfort next to it. On a scale form 1-10 how much pain/discomfort do you feel? 1 being very mild and 10 being severe.

If you have a specific medical conditions, massage/bodywork may be contraindicated (Should not be don). A referral from your primary care provider may be required prior to services being provided.

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension.  If I experience any pain or discomfort during this session, I will immediately inform the therapist that the pressure or strokes need to be to my level of comfort. I further understand that message/bodywork should not be construed 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 message therapist /body workers are not qualified to perform spinal or skeletal adjustment, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given, should be construed as such. I affirm that I have stated all my known medical conditions

______________________________________________________________ Date_________________

                                          Client Signature