Client Information Form

In order to maximize the effectiveness and safety of your massage sessions, please take time to carefully fill out this questionnaire. This information will be confidential.
Please remember to contact our office for an appointment!

Personal Information
Name: Date:
City: State:
Zip: E-Mail:
Home Phone: Work Phone:
Date of Birth: Occupation:
Emergency Contact: Relationship:
Home Phone: Work Phone:
Massage Information
How did you hear about?
Have you ever had a massage before?    (if yes, please answer the following)
When did you receive your last massage?
Do you receive massages regularly?
If so, how often?
What did you like about the massage?
What didn’t you like about the massage?
What are the benefits you are hoping to receive from massage therapy?
Medical Information
Name, address and phone number of your physician or other
health care provider:
has your permission to contact your physician or other
health care professional for any necessary information
Are you currently under the care of a physician or other health care professional?
If yes, for what reason?
Are you currently taking any prescription or non-prescription medications?
If yes, please list them and their purpose: Medications
Have you had any previous surgery?
If yes, please list the type of surgery and date of surgery:
Have you had any accidents or injuries that caused you to seek medical attention?
If yes, please list type of accident or injury and date of occurrence:
Are you pregnant?  If yes, what is your due date? 
Please check any of the following that apply: (current or prior conditions)
rash phlebitis arthritis cancer
open sores blood clots osteoperosis kidney disease
bruises high blood pressure bursitis diabetes
wart low blood pressure dislocations epilepsy
eczema heart disease broken bones allergies (please list)
impetigo stroke herniated disc
varicose veins sore or inflamed joints scoliosis
Do you wear contact lenses?  Dentures?  Hearing aid? 
Do you have any other medical conditions that I should be aware of before giving you a therapeutic massage?
Do you have any chronic sore or tense areas that require extra attention?
Selecting “I agree” in the signature field below and submitting this form constitutes a signature and indicates that you agree with the following statement:
I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder.  As such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations.  It has been made clear to me that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see my health care practitioner for any physical ailment that I might have.
Because the massage therapist must be aware of existing physical conditions, I have stated my medical history to the best of my knowledge, and will keep the massage therapist updated on my physical health.
Signature:  Date: 

Copyright © 2000 - 2024 In The Moment Massage Therapy Worked out with Canadian Health&Care Mall. All Rights Reserved.