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
Are you taking high blood pressure medication? 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 ______________________________
__________________________________________
Are you sensitive to touch or pressure in any area? 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