Massage Therapy Client Intake and Health History Form
Name: ________________________ Address: ______________________
City/Province: __________________ Postal Code: _______________
Home Phone: __________________ Cell Phone: _________________
Email: _________________________ Birthday: ________________
In case of emergency contact: ________________________________________
Recreational Activities: _______________________________________________
Are you receiving treatments from other health-care professionals?___________
If yes, which ones? _________________________________________________
Please check the following current conditions and P for any past conditions:
___heart, circulatory problems ___depression
___cancer/tumors
___blood clots
___vision problems
___fatigue
___high blood pressure
___seizures
___low blood pressure
___arthritis
___stroke
___asthma
___hearing conditions
___ tingling
___motor vehicle accident
___diabetes
___digestive problems
___chronic fatigue
___pregnancy: if so what is
the due date________
___fibromyalgia
___hernias
___skin disorders
___rashes
___headaches/migraines
___numbness
___stroke
___varicose veins
Other conditions not listed:
Allergies:
Surgeries, starting with the most recent:
Primary Concern:
Massage Therapy Informed Consent
I have informed the Massage Therapist of all my known physical conditions, medical conditions and
medications and I will keep the Massage Therapist updated on any changes to my health history.
I, _____________________________ have read, understood and completed, to the best of my
knowledge, the Massage Therapy Client History form and the Massage Therapy Informed Consent
form. I release the Massage Therapist from any and all liability from problems arising from the
treatment as a result of information not given or incorrectly given in this client history.
I,
understand that any massage appointments cancelled with less
than 24 hours notice are subject to a 50% charge for the cost of the cancelled appointment.
**If you have billable insurance, please give your insurance card to the front desk**
Client Signature:___________________________________Date: __________________________