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					                       Acuity Therapeutic Massage & Bodywork
                         Confidential Client Information and Health History


First Name:                             M.I.:                              Last Name:

Address:                                 City:                             St:             Zip:

Email
Address:                                               Referred By:

Phone (H):                               Phone (C):                        DOB:

Employer:                                              Occupation:

Emergency
Contact:                                 Phone:                            Relationship:

Marital Status:

                                                       If no, how
Is this your first professional                 Yes    frequently do you
massage?                                        No     get a massage?

What do you hope to accomplish
from today’s massage?                           Yes   No

Are you aware of any tension                    Yes    If yes,
holding spots in your body?                     No     location(s):

Describe any surgeries, hospitalizations, accidents or injuries you have had.
Less than 5 years ago:
More than 5 yrs ago:

What kind of care did you receive
for your accidents or injuries?

Do you feel that you have recovered             Yes
from these events?                              No     Please Explain:

Please list any medications (vitamins, herbs or pharmaceutical) taken now or at regular intervals
(include explanation of what medication is used to treat):


Are you currently under the care of             Yes
a physician?                                    No     Whom?
Please list reason(s):

Are there any other
health concerns you                                    If yes, please
wish to discuss today?            Yes   No             describe:
                              Acuity Therapeutic Massage & Bodywork
                               Confidential Client Information and Health History
PLEASE SELECT THE PLACES YOU ARE FEELING DISCOMFORT
                                                                               Are you currently experiencing the following
                                                                               conditions?
                                                                                 Flu or Cold Inflammation
                                                                                 Fever Infection

                                                                               Concerns or additional information you want
                                                                               your therapist to know:




 Please check any of the following conditions below that currently affect you or that you have experienced in the last 5 years.
 MUSCULOSKELETAL                                   CIRCULATORY                                   NERVOUS SYSTEM
   Fibromyalgia                                       Anemia                                        ALS
   Spasms/Cramps                                      Hemophilia                                    Multiple Sclerosis
   Sprains/Strains                                    Hypertension                                  Parkinson’s Disease
   Osteoporosis                                       Low Blood Pressure                            Bell’s Palsy
   Postural Deviations                                Raynaud’s Disease                             Neuritis
   Gout                                               Varicose Veins                                Spinal Cord Injury
   Osteoarthritis/Rheumatoid Arthritis                Heart Condition                               Stroke
   TMJ                                                Blood Clots/Phlebitis                         Trigeminal Neuralgia
   Cysts                                              Diabetes                                      Seizure Disorders
   Bursitis                                           Other                                         Numbness/Tingling/Twitching
   Plantar Fascitis                                                                                 Other
   Tendonitis                                      DIGESTIVE
   Torticollis                                        Ulcers                                     OTHER
   Whiplash Syndrome                                  Irritable Bowel Syndrome                      Insomnia
   Carpal Tunnel Syndrome                             Colitis                                       Anxiety/Panic Attacks
   Sciatica                                           Gallstones                                    PMS
   Thoracic Outlet Syndrome                           Hepatitis                                     Grief Process
   Headache                                           Crohn’s Disease                               Cancer
   Leg Pain                                           Diarrhea                                      Substance Abuse
   Arm Pain/Shoulder Pain                             Gas/Bloating                                  Pregnancy
   Low Back Pain                                      Indigestion                                   Chronic Fatigue
   Mid Back Pain                                      Other                                         HIV/AIDS
   Hip Pain                                                                                         Lupus
   Other                                           SKIN                                             Kidney Disease
                                                      Fungal Infections                             Bladder Infection
 RESPIRATORY                                          Acne                                          Postoperative Situation
   Pneumonia                                          Impetigo                                      Edema
   Sinusitis                                          Dermatitis/Eczema                             Other
   Asthma                                             Psoriasis
   Trouble Breathing                                  Open Wound or Sore
   Dizziness                                          Rashes
   Other                                              Warts/Moles
                                                      Athletes Foot
                                                      Other
      The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose
      disease, prescribe medications or manipulate bones. I further understand that massage therapy is not a substitute for medical
      attention or examination. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur
      with my health. I also understand that cancelled appointments without 24 hours notice (medical emergencies excluded) may be
      charged in full for the price of the missed session.
      Date: 12/10/2011
      Signature: ____________________________________________________________________________

				
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