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									                       Acuity Therapeutic Massage & Bodywork
                         Confidential Client Information and Health History

First Name:                             M.I.:                              Last Name:

Address:                                 City:                             St:             Zip:

Address:                                               Referred By:

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

Employer:                                              Occupation:

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
                                                                               Are you currently experiencing the following
                                                                                 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
      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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