Body Truing Massage Therapy: Client History Form
Please fill out to your fullest ability prior to your first appointment.
Contact Information *
Name
Your answer
Address
Your answer
Phone number
Your answer
Email address
Your answer
Date of Birth
Your answer
Would you like to receive our newsletter
Emergency Contact and Phone
Your answer
How did you hear about us?
Your answer
What is the main reason you booked an appointment?
Is there a specific area or problem you would like to address today?
Your answer
Please list 3 of your overall health goals.
How do you think therapeutic massage can help you achieve your goals?
Your answer
Have you had a massage before?
If so how often?
Your answer
Describe a typical day's activities
(work, exercise/week, kids, gardening, reading, tv, etc.)
Your answer
List any major injuries, accidents, and surgeries you've experienced.
This information is very important, even if it happened 20 years ago
Your answer
Are you currently taking any medications or drugs? (doctor or self-prescribed)
Please list the reason or condition each medication is treating
Your answer
Do you have any allergies?
(Specific oils, lotions, nuts or seeds, animals, etc.)
Your answer
Please write anything else you feel would be relevant for me to know about you and your health
Your answer
Please check next to any that apply
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.
Required
Thank you!
Receiving your responses before your first appointment is very helpful! If you have any questions please don't hesitate to email or call: marly@bodytruing.com 520.850.9123. I look forward to meeting you
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