A Touch of Balance
New Client History Form/Pain and Discomfort Chart
In order to maximize the effectiveness and safety of massage sessions, please take the time to carefully fill out this
questionnaire. This information will be treated confidentially. Your feedback is appreciated during and at the end of the
sessions to help in modifying the massage session to serve in the best possible way. Please print clearly.
Name:_________________________________________________ Today’s Date:____ /____ /____
Home Address:_______________________________________________ City _________________
Province_______________ Postal Code:______________________ Date of Birth:____ /____ /____
Cell #: :______________________________________ Home #:____________________________
Email: ___________________________________________________________________________
Occupation(s):____________________________________Referred by: _______________________
Is the massage covered by your insurance? ___Yes ___No
*** If NO, Please inquire about special discount to make regular treatment more affordable.
1) Have you had any previous experience with massage? ___YES ___NO
If yes, please explain whether for stress relief/relaxation or treatment of a specific condition diagnosed
by a physician:
_________________________________________________________________________________
2) FEMALE CLIENTS: Are you pregnant? If so, due date: __________________________________
3) Please mark an [X] for all conditions that apply now. Put a [P] for past conditions.
[ ] headaches, migraines
[ ] injuries to face or head
[ ] sinus problems
[ ] jaw pain, TMJ problems
[ ] asthma or lung conditions
[ ] constipation, diarrhea
[ ] abdominal or digestive problems
[ ] chronic pain
[ ] muscle or joint pain
[ ] muscle, bone injuries
[ ] numbness or tingling
[ ] sprains, strains, dislocations
[ ] arthritis, tendonitis, bursitis
[ ] scoliosis, spinal column injury
[ ] osteoporosis
[ ] bone or joint disease
[ ] cancer, tumors
[ ] diabetes
[ ] heart, circulatory problems
[ ] fatigue
[ ] dizziness, vertigo
[ ] tension, stress
[ ] depression
[ ] sleep difficulties
[ ] allergies, sensitivity
[ ] skin rash, athletes foot, nail fungus
[ ] infectious disease
[ ] blood clots
[ ] varicose veins
[ ] high/low blood pressure
[ ] nervous system disorder
[ ] other condition not listed
4) Explain any areas noted above and note if you are currently seeing a doctor for any of the conditions:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
PLEASE CONTINUE ON THE BACK PAGE
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5) Current medications, vitamins, herbs, and nutritional supplements you are taking including common
nonprescription medications:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
6) Have you had any surgeries or injuries within the last five years? If yes please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
7) Please explain your current exercise and stretching routine.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
8) What is your goal/concern for today’s session?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
9) Are you interested in adding prayer to your session today? ___YES___NO
How can I pray for you?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
10) What are your long-term health goals?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Please check off any options you would like more information on:
( ) Nutritional Supplements
( ) Life Purpose Coaching
( ) Ioncleansing
( ) Christian Massage
( ) Stretching Routines
( ) Pathway to Purpose – Book Study Club
( ) Walking Club
( ) Prayer Chain
( ) Sign me up for Monthly Newsletters/Promo Information
Preferred Email: _______________________________________________ ( ) check if same as above
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PAIN & DISCOMFORT CHART
1) Please indicate the areas where you have pain ( X ) and/ or any Numbness ( N ). If your pain
seems to refer or “shoot out” to another area of your body please indicate with arrows.
2) For how long have you experienced pain/discomfort in the areas indicated above?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3) Describe what you do that causes pain, and what activities make it worse:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
I HAVE STATED ALL CONDITIONS THAT I AM AWARE OF AND THIS INFORMATION IS TRUE AND
ACCURATE. I WILL INFORM YOU OF ANY CHANGES IN MY HEALTH STATUS BEFORE MY NEXT MASSAGE
SESSION. I UNDERSTAND THAT A HEALTH PRATITIONER CANNOT DIAGNOSE AND IS NOT A
SUBSTITUTE FOR SEEING A PHYSICIAN. _______INTIAL
I UNDERSTAND THAT WHEN I MAKE A BOOKING THE TIME IS SET ASIDE SPECIFICALLY FOR ME AND
THEREFORE OUT OF RESPECT IF I AM UNABLE TO GIVE 24 HOURS NOTICE OF CANCELLATION I
AGREE TO PAY FOR MY SESSION. ________ INTIAL
Please sign here _______________________________________ _______________________ Date: _____________________
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