Body Truing Massage Therapy: Client History Form
Please fill out to your fullest ability prior to your first appointment.
Date of Birth
Would you like to receive our newsletter
Emergency Contact and Phone
How did you hear about us?
What is the main reason you booked an appointment?
Is there a specific area or problem you would like to address today?
Please list 3 of your overall health goals.
How do you think therapeutic massage can help you achieve your goals?
Have you had a massage before?
If so how often?
Describe a typical day's activities
(work, exercise/week, kids, gardening, reading, tv, etc.)
List any major injuries, accidents, and surgeries you've experienced.
This information is very important, even if it happened 20 years ago
Are you currently taking any medications or drugs? (doctor or self-prescribed)
Please list the reason or condition each medication is treating
Do you have any allergies?
(Specific oils, lotions, nuts or seeds, animals, etc.)
Please write anything else you feel would be relevant for me to know about you and your health
Please check next to any that apply
Arthritis or Joint Disease
High Blood Pressure
Low Blood Pressure
Muscle or Tendon Sprain
Spinal/Vertebral Disk Problems
I have filled out this form to the best of my knowledge: check box to agree
Upon arrival of your first appointment you will be asked to read and sign a Client Informed Consent Statement and Waiver.
Receiving your responses before your first appointment is very helpful! If you have any questions please don't hesitate to email or call:
520.850.9123. I look forward to meeting you
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