New Client Form: Please print and fill out the form below for your first massage appointment.

Name:__________________________   Todayʼs Date:_______________Referred by:___________________

Date of Birth:______________________Phone:______________________Email:  _____________________

Address:_______________________________  City:_________________________Zip:_________________

Best way to contact you:  ____ Phone  ____ Text  ______ Email

What are your treatment goals today (e.g., reduce pain, relaxation, reduce stress, etc.)?

List/describe Current medical issues:

Medications and conditions:

Allergies/allergic reactions:

History of serious illnesses, surgeries, and/or injuries:

Women only:  Could you be pregnant at this time?

Please mark “C” for currently experiencing and “P” for previously experienced:

__High blood pressure                    __Fractures                                    __Surgery

__Stroke                                          __Sprains/Strains                           __Dental Surgery

__Heart condition                           __Numbness/Tingling                    __Tumors

__Arthritis                                      __Automotive Accidents                __Cancer

__Joint pain                                    __Osteoporosis                               __Shingles/Herpes/Zoster

__Lupus                                          __Bursitis                                       __Recurrent Headaches

__Fibromyalgia                              __Sciatic                                         __Digestive issues

__Diabetes                                     __Inflammation                               __Skin Infections

__Serious Cuts/Burns/Bruises       __Varicosities                                  __Other (Describe)

The information that you provide is important in helping me to devise an appropriate treatment plan. Massage represents a therapeutic treatment modality that can be beneficial for a variety of conditions, but it cannot be used to diagnose medical conditions. This information is CONFIDENTIAL and will not be discussed with anyone else.

Signature____________________________________________________  Date____________________________

This lets me know the history and current state of your health. What questions, concerns, goals, regarding wellness can I help you with?