HTML Preview Massage Medical History Form page number 1.
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