Massage Client Health History Form at a glance
What it is: The Massage Client Health History Form is a Client Information and Release Form for a massage provided for relaxation, stress reduction, and relief of muscular tension.
Who signs: You sign on the Signature line and enter the Date.
A filled-in Massage Client Health History Form example: an adult client fills out the form
How to fill out Massage Client Health History Form, box by box
Name, Birth Date, Address, Phone Number(s) and E-mail Address
Enter your Name, Birth Date, Address, City, State and Zip.
Enter your Phone Number(s) as Home, Work and Cell, and your E-mail Address.
Referred By and Is this your first massage?
Enter who you were Referred By, and fill in Is this your first massage?
General Medical History: Arthritis to Fibromyalgia
Check the box if you have or have had recent problems with Arthritis, Bursitis, Back Pain, Neck Pain, Arms / Hands (Pain), Hips / Legs / Feet (Pain), Headaches, Swollen Joints or Fibromyalgia.
High Blood Pressure to Constipation
Check the box for High Blood Pressure, Low Blood Pressure, Poor Circulation, Anemia, Stroke, Chest Pain, Seizures / Convulsions, Heart Conditions or Constipation, if you have or have had recent problems with it.
Sinus / Allergies to Athlete's Feet, with Pregnant?
Check the box for Sinus / Allergies, Hematomas, Phlebitis, Vericose Veins, Cancer, Skin Conditions, Menstrual Pain, Warts or Athlete's Feet, if you have or have had recent problems with it. For Pregnant?, check the box and write the # of months.
Acute injury, surgery, medical conditions, stress and tension, contacts and problem areas
Enter Have you recently suffered an acute injury?, Have you had any recent surgery? and Do you have any other medical conditions that I should be aware of?
Enter Where do you carry your stress and tension?, Do you wear contacts? and Do you have any problem areas / injuries?
Prescription medications, allergies and exercise activities
Enter Do you take any prescription medications? and Do you have any allergies? Yes or No, and if yes what are you allergic to?
Describe exercise activities that you do. Include Frequency.
Sensitivity to touch, pressure, goal and additional comments
Enter Are you very sensitive to touch / pressure in any areas?, What type of pressure do you like? and What is your goal in the session today?
Please list any additional comments regarding your health and well being if needed.
Signature and Date
You sign on the Signature line and enter the Date.
Consent for minors: Signature of Guardian
Consent for minors is required prior to treatment.
For minors, the Guardian signs on the Signature of Guardian line and enters the Date, the Printed name of Guardian and the Phone number the Guardian can be reached in case of emergency.
More rules for Massage Client Health History Form
Circle any areas of pain, injury, tension, or restriction of movement.
Your answers to these questions will be discussed with you prior to your session.
Please take a moment to carefully read the following information and sign where indicated.
If you experience any pain or discomfort during this session, you will immediately inform the practitioner so that the pressure and / or strokes may be adjusted to your level of comfort.
Massage should not be considered as a substitute for medical examination, diagnosis, or treatment.
Massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, or treat any physical or mental illness, and nothing said in the course of the session(s) given should be considered as such.
No comments or gestures that are sexual in nature will be tolerated by the massage therapist. In the event that you violate this policy, your session will be immediately terminated.
Because massage is contraindicated under certain medical conditions, you affirm that you have stated all your known medical conditions, and answered all questions honestly.
You agree to keep the practitioner updated as to any changes in your medical profile, and understand that there shall not be liability on the practitioner's part should you forget to do so.
Sources
[1] Massage Client Health History Form (the Official source link on this page).
