Client Health History Form | Infinite Evolution

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Occupation

Phone

Date of Birth

Alt Phone

Areas of complaint, pain or tension

Health History

Have you had professional massage before? If yes, when was your last appointment?

Yes
No

Last Appointment

Do you wear contacts or dentures?

Yes
No

Explanation

Do you have skin problems or allergies?

Yes
No

Explanation

Have you suffered a recent injury?

Yes
No

Explanation

Do you have varicose veins or blood clots?

Yes
No

Explanation

Do you have Arthritis?

Yes
No

Explanation

tension any advanced

Do you have any heart problems?

Yes
No

Explanation

Do you exercise or participate in a sport?

Yes
No

Explanation

Are you pregnant?

Yes
No

What month? Due Date?

Do you have blood pressure problems?

Yes
No

Explanation

Do you take any prescription drugs or street drugs?

Yes
No

If yes, for what conditions?

Do you have any other medical conditions or diagnosis past or present?

Yes
No

Explanation

24hr advanced notice required for changing or canceling any appointment to avoid cancellation fees.

I understand that massage and other natural therapies given here are for stress reduction, relief from muscular tension or spasm, or for increasing the circulation and energy flow. I understand that the massage therapist does not diagnose any physical or mental disorder. The therapist does not prescribe medical treatment or pharmaceuticals, nor perform any spinal manipulations. These therapies are not a substitute for medical examinations and/or diagnosis and it is recommended that I see a physician for any physical ailment that I might have. With this in mind I agree to have massage therapy, aromatherapy, or energy therapy and hold the therapist harmless for any problem that might arise as a result of the session.

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