Client No _________________
Today’s Date _______________

Name ____________________________    DOB ____________	Home phone ______________
Address ______________________________________________  	Cell ______________________
City ____________________________State ______ Zip ________	Work ____________________
Email _____________________________________________
Emergency Contact (Relationship) _____________________________	Phone ______________

Occupation _____________________________________________
How did you hear about me (us) ____________________________

MEDICAL 
(check all that apply)
___ allergies	___ constipation	___ heart	___ Pregnant
___ anemia	___ Crohn’s	___ herpes	___ stroke
___ arthritis	___ diabetes	___ hernia	___ tinnitus
___ asthma	___ diarrhea	___ HIV/AIDS	___ tuberculosis
___ cancer	___ epilepsy	___ herpes	other____________
___ colitis	___ gout	___ migraine	other____________
Cancer (describe type, stage, with dates) ____________________________________________
SURGERY
Description with date: ___________________________________________________________
______________________________________________________________________________
Accidents (what kind)	Injury	Date
_________________________	_____________________	_____________
_________________________	_____________________	_____________
_________________________	_____________________	_____________
_________________________	_____________________	_____________

•	Do you receive massage? ________ Last date received ___________
•	Present complaint _________________________________________
•	How long has you had this complaint _______________________
•	Did it happen gradually or suddenly ________________________
•	What caused this to happen ______________________________
•	What helps this condition ________________________________
•	What aggravates this condition ____________________________
•	Are you under Doctor’s care for this ________________________
•	On a scale from 1 – 10, 10 being unbearable pain, how much pain are you in today _______
•	What do you wish to gain from massage ______________________________
•	List current medications/purpose/effectiveness and/or side effects____________________
______________________________________________________________________________
•	Do you use:
•	 tobacco/how much ___________________________
•	 alcohol/how much ____________________________
•	 caffeine /how much ___________________________
•	What exercise do you do regularly/how often _____________________________________
______________________________________________________________________________
Additional comments ____________________________________________________________
______________________________________________________________________________

Using the diagrams below circle the area(s) of pain or discomfort.

Client Agreement
I _______________________ understand that massage therapy is not a substitute for medical treatment from a qualified specialist.  I also understand that massage therapists are not qualified to diagnose or prescribe medications.  There are certain conditions in which massage therapy is inadvisable and if this is the case, the therapist may not be able to work with me.  
To the best of my knowledge I agree that I have given a complete health history and agree to keep the therapist informed of any changes in my medical condition and will not hold the therapist liable for any effects that may arise from my session.  I agree to communicate any discomfort during my session whether from pressure, heat or other causes. 
I am aware that should I need to cancel my appointment in less than 24 hours from my scheduled appointment time that I am responsible for payment in full.  I also understand that if I am late for my appointment, the therapist may not be available to give me the full session and I am responsible for the full session charge.
I have read and understand this agreement.
______________________________	______________________
Signature	Date