CONFIDENTIAL CLIENT INFORMATION AND HEALTH HISTORYPlease fill out this form prior to your first appointment. Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Employer Occupation Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Relationship * Referred by First Name Last Name Is this your first professional massage? * Yes No If no, how frequently do you get a massage? What do you hope to accomplish from today’s massage? Are you aware of any tension holding spots in your body? Option 1 Option 2 If yes, location(s) of tension holding spots: Describe any surgeries, hospitalizations, accidents or injuries you have had: Less than 5 years ago: Describe any surgeries, hospitalizations, accidents or injuries you have had: More than 5 years ago: What kind of care did you receive for your accidents or injuries? Do you feel that you have recovered from these events? Please explain: Do you have any chronic, ongoing pain that you deal with on a regular basis? Please explain: Describe what activities cause this pain and/or make it worse: Are you receiving any other type of medical treatment? Please explain: Please list any medication (vitamins, herbs or pharmaceutical) taken now or at regular intervals (include explanation of what medication is used to treat): Are you currently under the care of a physician? Yes No Name of Physician First Name Last Name Please list reason(s): Are there any other health concerns you wish to discuss today? Yes No If yes, please describe health concerns: Thank you! Looking forward to seeing you soon.
