Client History Form

Your Name:

Address:

Contact Information:

Referred by:

Is this your first time getting a massage?

Birth Date:

Upload photo of Drivers License:

(Front)
(Back)

Upload photo of Medical Card:

Check the box if you have, or have had, recent problems with any of the following:

Anemia

Arms / Hands (Pain)

Arthritis

Athlete's Foot

Back Pain

Bursitis

Cancer

Chest Pain

Constipation

Fibromyalgia

Headaches

Heart Conditions

Hematomas

High Blood Pressure

Hips / Legs / Feet (Pain)

Low Blood Pressure

Menstrual Pain

Neck Pain

Phlebitis

Poor Circulation

Pregnant

Seizures / Convulsions

Sinus / Allergies

Skin Conditions

Stroke

Swollen Joints

Vericose Veins

Warts

Any additional notes or medical issues I should be aware of: