Client History Form

Sarah Lawrie, Massage Therapist

Name______Telephone(s)______

Address______Email ______

City/State/Zip______Birthdate ___/____/______

How did you hear about my practice?______

1. Occupation/daily activity. Briefly describe how your using your body typically in a day's time:

2. How would you rate your stress level on scale of 1 to 10 (1 = no stress)

3. Describe your exercise habits/meditation routines/de-stressing activities:

4. Do you have any chronic, ongoing conditions that you deal with on a regular basis? Please explain.

5. Are you under the care of a medical/holistic practitioner? (i.e. MD, OD, ND, Physical Therapist, Psychotherapist, Chiropractor, bodywork therapist,etc. ). Please explain.

6. Please list any medications you currently take. If you experience side effects, please list them beside the medication.

7. Have you had any injuries or accidents?

More than 5 years ago (car accidents, falls, sports injuries, birth trauma, etc):

Within last 5 years (included date estimate):

Do you feel you’ve fully recovered from these events?

8. Allergies/skin sensitivity? Please list.

Please mark any of the following conditions which you currently have or have experienced in the past, indicating the dates to the spaces at the right. Some may be contraindications for massage.

Boils / Psoriasis / Embolism / Varicose veins
Fungal infections / Burns / Deep Vein Thrombosis / GERD (reflux disease)
Poison Ivy/Oak / Gout / High blood pressure / Ulcers
Herpes / Acne / Heart attack / GI tract conditions
Warts / Congestive Heart Failure / Heart disease / Sciatica
Eczema / Diabetes / Low blood pressure / Foot pain
Diarrhea / Hypothyroidism / Osteoporosis/penia / Carpal Tunnel Syndrome
Pregnancy / Hyperthyroidism / Rheumatoid Arthritis / Thoracic Outlet Syndrome
TMJ Syndrome / Asthma / Osteoarthritis / Herniated disc
Stroke / Emphysema / Sleep Disorders / Back surgery
Multiple Sclerosis / Sinusitis / Mononucleosis / Lupus
Depression / Allergies / Ligament tears/sprains / Swelling
Anxiety disorder / Urinary tract infection / Tendon strain / Bursitis
Headaches / Kidney stones / Tendonitis / HIV/AIDS
Trigeminal Neuralgia / Renal failure / Shin Splints / Chronic Fatigue
Numbness in limbs / Frequent urination / Whiplash / Flu
Fibromyalgia / Hepatitis / Torn cartilage / Fever (current or last week)
Hepatitis A, B or C
History of trauma / Spondylothesis / Scoliosis / Undiagnosed rash/skin irritation

Other Please describe any other conditions (with dates) ______

Cancer Please describe with dates:______

Surgery Please describe with dates:______

Please mark on the diagram your areas

of greatest tension or discomfort.

Anything else you'd like to share/feel it's helpful for me to know about you, your current state, your past?

I, ______, the undersigned, do hereby fully and willingly allow Sarah Lawrie to offer me massage therapy. I confirm I have consulted a medical doctor for all of the conditions checked above and have received authorization to have massage (where approval is necessary). By signing this release, I do hereby waive and release Sarah Lawrie from all liability- past, present and future. Furthermore, I have read and agree to the policies established for this massage practice.

Client Signature ______Date______