Medical History

Account Number___________________________________________

Client__________________________________ Occupation______________________________________

Date of Birth___________________________

Address:_________________________________________________________________________________________________________________

City: __________________________________________ State: _______ Zip:________

Phone #: _____/_____-________ Ss# ______-______-______ Driver’s License #_____________________

Email: _____________________________________________________ Would you like to recieve emails? Yes or No

Physician: _________________________________________________ Phone: _________________________________________

How many massages have you had before today? 0 1-5 5-10 10+

Reason for your visit today: _________________________________________

Referred by: ____________________________________________________

Check any of the following that presently apply to you:

___disease (any) ___headache ___bone/joint disorder ___cancer ___blood clots ___pregnancy ___varicose veins ___injury

___bruises ___constipation ___recent surgery ___fever ___rash ___cardiac problems ___pregnant ___herpes ___arthritis

___hernia ___open cuts/sores ___vertigo ___fibromyalgia ___HIV ___hepatitis ___high/low blood pressure

___inflammation/swelling ___allergies (lotions, scents)

Other ______________________________________________________

Explanation:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medications ____________________________________________________________________________________________________

Reason for the Medication______________________________________________________________________________________________

Surgery/Procedures & Dates____________________________________________________________________________________________