City/ State/ ZIP ___________________________
Birth Date ______________SSN _____________
Primary Health Care Provider ________________
Permission to consult with primary provider, if appropriate? Please initial if yes______Yes ______No
I understand that appointments cancelled with less than 24-hour notice will be billed at the full price.
MASSAGE HISTORY/ TREATMENT INFORMATION
I ask these questions to better tailor my massage to your needs and to protect the health and
well-being of my clients. Please answer them as best you are able.
What results do you want from your massage today? __________________________________________
Are you currently experiencing any of the following? If yes, please explain.
Pain or Tenderness _____ Yes___ No_____________ Stiffness ___Yes ___No____________________
Numbness or Tingling ____Yes ___No_____________ Swelling ___Yes ___No ____________________
What makes it better? __________________________ Worse?_________________________________Please check the areas of your body that you give permission to receive massage.
____Back_____Legs ___Buttocks____Arms____Abdomen___Chest ___Neck___Head ___Face___Feet
Are you currently seeing a medical practitioner, including chiropractor, acupuncturist, DO, naturopath, etc., including psychotherapist or support group? If yes, please explain. ___Yes___No_____
List stress reduction and exercise activities, with frequency. ____________________________________
List medication, including aspirin and ibuprofen, taken today. ___________________________________
PREVIOUS HISTORY Include year and treatment received.
Accidents ___________________________________________________________________________ ____________________________________________________________________________________