Client Health History

Please print clearly and complete both sides of this form. This information is critical to your treatment as it may affect the manner in which your therapist structures your session. All information is kept strictly confidential.

Name: ____________________________________________________ Date:_______________________

Address:_______________________________________________________________________________ Street City State Zip

Home/Cell phone:_______________________________________________________________________

Referred by?_______________________________________________________________________

E-mail___________________________________ Male / Female Date of Birth:___________________

Have you ever had a therapeutic massage before? Yes No Many Times Please list all medications/ supplements that you are currently taking:

Are you currently experiencing any of the following? (please circle)

Sunburn Cuts, Burns, BruisesInflammation Skin Rash Herpes/ Cold Sore/ ShinglesHeart Condition Pregnancy InfectionsBlood thinners Cancer Numbness/TinglingPoison Ivy Cold or flu Other: ________________________________Headache/ Migraine

Circle any areas where you are experiencing pain/discomfort:

How much water do you drink per day? How many hours per week do you participate in activities?

2 to 4 glasses Less than an hour 5 to 7 glasses 1 to 3 hours8 or more 4 or more hours

What are your goals for this massage? If you have had a massage before, what is your Pressure preference?Relaxation light / meditative Injury Rehabilitation heavy / invigorating Maintenance Massage deep / trigger point

Please list if you have or have had any injuries and the dates of them, as well as any surgeries and dates.

______________________________________________________________________________________

______________________________________________________________________________________

Any other health conditions I should be aware of?

______________________________________________________________________________________

Please read the following and sign

I verify that all information provided is correct and current to the best of my knowledge. I understand that any information provided by the therapist is for client educational purposes and is neither diagnostic nor prescriptive in nature. I hereby give my consent to receive massage therapy at Body Benefit Massage Therapy and will not hold Body Benefit Massage Therapy, its staff, or the massage therapist either responsible and/or liable for any injury or loss of property.

Signature__________________________________________________Date_________________