Client info sheet

Name ______________________________________ Phone ( ) ____________________ DOB _________

Address ________________________________ City ________________ State ________ Zip __________

E-mail: _________________________________________________________________________________

Referred by: _________________________________________Phone ( )__________________________

In case of emergency: ___________________________________________ Phone ( )_____________

Occupation ________________________

Male Female

Physician____________________________________________

Please take a moment to carefully read the following information and sign where indicated. If you have a specific

medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary

care provider may be required prior to service 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or 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 of which I am aware. I understand that massage/bodywork

practitioners are not qualified to perform spinal or skeletal adjustments, 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. Because massage/ bodywork should not be performed 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 be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive

remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

Client Signature ________________________________________ Date _____________________________

Practitioner Signature __________________________________ Date _______________________________

Do you frequently suffer from stress? Yes No

Do you have diabetes? Yes NoDo you experience frequent headaches? Yes No

 Are you pregnant? Yes No

Health Insurance Carrier ____________________________________________________________________________________

 Do you suffer from arthritis? Yes No

 Are you wearing contact lenses? Yes No

Are you wearing dentures? Yes No

 

Do you have high blood pressure? Yes No

Are you taking high blood pressure medication? Yes No

 

Do you suffer from epilepsy or seizures? Yes No

Do you suffer from joint swelling? Yes NoDo you have varicose veins? Yes NO

Do you have any contagious diseases? Yes No

Do you have osteoporosis? Yes No

Do you have any allergies? Yes NO

Do you bruise easily? Yes NoAny broken bones in the past two years? Yes No

Any injuries in the past two years? Yes No

Do you have tension or soreness in a specific area?

Please specify ______________________________

__________________________________________

 

Do you have cardiac or circulatory problems? Yes No

 

Do you suffer from back pain? Yes No Do you have numbness or stabbing pains? Yes No

 Are you sensitive to touch or pressure in any area? Yes No

 

Have you ever had surgery? Explain below. Yes No

________________________________________________________________________________________

 Other medical condition, or are you taking any meds? Yes No

How recently?_________________

What are your massage or bodywork goals?______________________________________________________________________

What kind of pressure do you prefer?

light medium firm

If you answer “yes” to any of the following questions, please explain as clearly as possible.

Consent to Treatment of Minor:

 

By my signature below, I hereby authorize ______________________________________ to administer massage, bodywork, or

somatic therapy techniques to my child or dependent as they deem necessary.

Signature of Parent or Guardian ________________________________________________________________________ Date ____________________

Screening Questionnaire form
Body Map for Clients
Client Feedback form
Physician's Permission form
Physician's Referral form