health information form

1. ROCHELLE’S TOUCH INSTITUTE
MASSAGE CLINIC
HEALTH INFORMATION FORM
Date: ______________
A.Client Information:
Client’s Name: _____________________
Age: _____________________________
Sex: ______________________________
Address: __________________________
__________________________________
Phone No: _________________________
Mobile No: ________________________
Citizenship: ________________________
Religion: __________________________
Occupation: ________________________
Emergency contact: __________________
MASSAGE HISTORY/TREATMENT INFORMATION
Have you ever received a professional massage?
( ) Yes ( ) No if yes, frequency
_________________________
What results do you want from your massage sessions?
___________________________________________
___________________________________________
Prioritize the area of your body that you would prefer to
be massage.
_____________________________________________
_____________________________________________
Please check the areas of your body that you give permission
Received massage?
( ) back ( ) legs ( ) buttocks ( ) arms ( ) abdomen
( ) chest ( ) neck ( ) head ( ) face ( ) other
Are you currently seeing a medical practitioner?
Please explain if yes. ( ) Yes ( ) No

2. ______________________________________
______________________________________
List stress reduction and exercise activities. Include
frequency. _______________________________
________________________________________
List current medications, including aspirin, ibuprofen,
Etc.
________________________________________
________________________________________
PREVIOUS HISTORY
(Include year and treatment)
Surgeries: _______________________________
________________________________________
Accidents: _______________________________
________________________________________
HEALTH HISTORY
MUSCULOSKELETAL
___bone or joint disease ____________________
___tendonitis _____________________________
___broken/fractured bones __________________
___arthritis_______________________________
___low back/hip/leg pain ___________________
___neck/shoulder/arm pain__________________
___spasms/cramps________________________
CIRCULATORY
___heart condition _________________________
___varicose veins__________________________
___high blood pressure______________________
___low blood pressure______________________
___breathing difficulty______________________
___allergies_______________________________
___other _________________________________
INFECTIOUS
___disease name(s) _________________________
SKIN
___allergies______________________________

3. ___rashes________________________________
___athletes foot __________________________
___warts ________________________________
___other _________________________________
DIGESTIVE
___ constipation ___________________________
___gas/bloating ____________________________
___other _________________________________
NERVOUS SYSTEM
___herpes/shingles _________________________
___numbness/tingling ______________________
___chronic pain ___________________________
___fatigue________________________________
___sleep disorders _________________________
REPRODUCTIVE
___pregnant? Stage ________________________
___PMS _________________________________
___other _________________________________
OTHER
___cancerous _____________________________
___diabetes ______________________________
___drug/alcohol/addiction ___________________
___eating disorders ________________________
___depression ____________________________
___nicotine/caffeine addiction ________________
_________________________________________
Massage Therapist
Signature Printed Name
It is my choice to receive massage therapy. I realize that the treatment is being given for the

4. well-being of my body and mind. This includes stress reduction, relief from muscular tension,
spasm or pain, or for increasing circulation or energy flow. I agree to communicate with my
practitioner any time I feel like my well being compromised.
I understand that massage practitioners do not diagnose illness, disease, or any physical or
mental disorder nor do they prescribe medical treatment, pharmaceuticals or perform spinal
thrust manipulations. I acknowledge that massage is not a substitute for medical examinations or
diagnosis and that it is recommended that I see a primary health care provider for that service.
I have stated that all medical conditions that I am aware of and will update the massage practitio-
ner of any changes in my health status.
Signature: ___________________________Date: ______________