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Client Information and Release Form
Name ____________________________________________________ Birth Date ____________________
Address ________________________________________________________________________________
City __________________________________________ State ________ Zip ________________________
Phone Number(s) ___________________ Home __________________ Work __________________ Cell
E-mail Address__________________________________________________________________________
Referred By ________________________Is this your first massage?________________________________
General Medical History
Check the box if you have or have had recent problems with any of the following:
Arthritis
Bursitis
Back Pain
Neck Pain
Arms / Hands (Pain)
Hips / Legs / Feet (Pain)
Headaches
Swollen Joints
Fibromyalgia
High Blood Pressure
Low Blood Pressure
Poor Circulation
Anemia
Stroke
Chest Pain
Seizures / Convulsions
Heart Conditions
Constipation
Sinus / Allergies
Hematomas
Phlebitis
Vericose Veins
Cancer
Skin Conditions
Pregnant? ____# of months
Menstrual Pain
Warts
Athlete’s Feet
Please circle any areas of pain, injury, tension, or restri
c
tion of movement.
Massage Client Health History Form
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