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Client_Information_Sheet

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					Client Information
Name: _____________________________ Telephone: ___________________ Date of Birth: ___________ Address: ________________________________ City: __________________State: _____ Zip: __________ Email Address:_______________________________________@__________________________ Referred by: ________________________________________ Telephone: ___________________ In case of emergency: _________________________________Telephone: ___________________ General Information Occupation: _____________________Age: ____ Male

Female

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided. ___Yes ___No Have you ever experienced a professional massage or body work session? How recently?_____ If you answer “yes” to any of the following questions, please explain as clearly as possible. ___Yes ___No Do you frequently suffer from stress? ___Yes ___No Do you have diabetes? ___Yes ___No Do you experience headaches? ___Yes ___No Are you pregnant? ___Yes ___No Do you suffer from arthritis? ___Yes ___No Are you wearing contact lenses? ___Yes ___No Are you wearing dentures? ___Yes ___No Do you have high blood pressure? ___Yes ___No Do you suffer from epilepsy or seizures? ___Yes ___No Do you suffer from joint swelling? ___Yes ___No Do you have varicose veins? ___Yes ___No Do you have any contagious diseases? ___Yes ___No Do you have osteoporosis? ___Yes ___No Do you have any allergies THERAPIST NOTES: ___Yes ___No Do you have numbness or stabbing pains anywhere? ___Yes ___No Are you very sensitive to touch or pressure in any area? ___Yes ___No Have you ever had surgery? Explain below: ______________________________ ___Yes ___No Do you have any other medical conditions that I should be aware of? Comments; ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ___Yes ___No Do you bruise easily? ___Yes ___No Have you had any broken bones in the past two years? ___Yes ___No Have you been in an accident or suffered any injuries in the past two years? ___Yes ___No Do you have tension or soreness in a specific area? Please specify:________________ ___Yes ___No Do you have cardiac or circulatory problems? ___Yes ___No Do you suffer from back pain?

Please complete page 2.

Essence of Tranquility – blb 0206 smb

Medical Information
List accidents/injuries, hospitalizations, and surgeries: when they occurred and treatment received.

Are there lingering effects from the above or do you feel you have recovered?

Chronic ongoing pain?

No

Yes, please describe any care or treatment you received.

Do activities affect the pain?

No

Yes, please describe.

Are you currently being treated medically or taking prescribed drugs?

No

Yes, please describe.

Please list all over the counter, supplements, and/or herbs taken and why?

    



TMJ Tendonitis Whiplash Strains/Sprains Chronic pain in:  Neck  Low-back  Mid-back  Upper-back  Hip  Arm  Leg  Shoulder  Wrist/Hand On computer more than 2hrs/day. No. of hrs:____

               

Asthma Heart problems:____________ Stroke Palpitations Anemia Hemophilia Hypertension Low Blood Pressure Blood clots/Phlebitis Fungal infections Athlete’s Foot Impetigo Eczema/Dermatitis Psoriasis Easily irritated skin Other skin:_______________

          

Cancer Kidney disease Hepatitis HIV/AIDS Lupus High stress Grieving Anxiety/Panic Attacks Bipolar syndrome PMS/Menopause difficulties Poor sleep/Insomnia

Any other items of concern or continuation from above please list here:
_________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________

Client Signature___________________________________

Date___________

Therapist Signature________________________________ Date___________
Essence of Tranquility – blb 0206 smb


				
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posted:12/26/2009
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