Confidential Client Information Form printable pdf download

BELLE ROSS SPA & SALON

CONFIDENTIAL CLIENT INFORMATION FORM- PLEASE PRINT

Name:________________________________________________________________D.O.B:_____________________________Email:___________

Address:____________________________________________________________City:_________________________ST:_________Zip:_________

Phone: (Home)(______)_______________________________(Work)(______)____________________________(Cell)(______)_________________

Employer:_____________________________________________________________________Occupation:________________________________

Emergency Contact Person:_________________________________________________________________Phone:___________________________

Referred by:________________________________________________________________________

Previous Experience with Massage:___________________________________________________________________________________________

Date of Last Massage:________________________________________________________________

Primary Reason for Appointment/Areas of Pain or Tension:_________________________________________________________________________

________________________________________________________________________________________________________________________

Because massage has both physical and mental/emotional affects it is important to keep the massage therapist aware of your health status. Are you

currently seeing a health care provider? NO________ YES________

Permission to contact health care provider or massage therapist/physical therapist/ occupational therapist/ chiropractor

Physician:__________________________________________________Phone:______________________________Initial for Permission:_________

Therapist:__________________________________________________Phone:______________________________Initial for Permission:_________

Please mark (X) to all conditions that apply now. Put a P for past conditions. Put F for family history of illness.

___ Headaches, Migraines

___ Chronic Pain

___ Fatigue

___Vision Problems, Contact Lenses

___ Muscle or Joint Pain

___ Tension, Stress

___ Hearing Problems, Deafness

___ Muscle, Bone Injuries

___ Depression

___ Injuries to face or head

___ Numbness or Tingling

___ Sleep Difficulties

___Sinus Problems

___ Sprains, Strains

___ Allergies, Sensitivity

___ Dental Bridges, Braces

___ Arthritis, Tendonitis

___ Rash, Athletes Foot

___ Jaw Pain, TMJ Problems

___ Cancer, Tumors

___ Infectious Disease

___ Asthma or Lung Conditions

___ Spinal Column Disorders

___ Blood Clots

___ Hernia (Hiatal/Inguinal)

___ Diabetes

___ Varicose Veins

___ Constipation/Diarrhea

___ Pregnancy (Trimester:_____)

___High/Low Blood Pressure

___ Congestive Heart Failure

___ Skin Disorders

___ Other (_____________)

Current medications, including asprin, ibuprofen, herbs, vitamins, etc:_________________________________________________________________

________________________________________________________________________________________________________________________

Surgeries:________________________________________________________________________________________________________________

Accidents:_______________________________________________________________________________________________________________

Please list all forms and frequency of stress-reductions activities, hobbies, exercise, or sports participation:

________________________________________________________________________________________________________________________

Please read the following statements and sign below

I understand this massage is NOT a replacement for medical care.

I have disclosed any conditions that massage therapy may aggravate.

I understand that any illicit or sexually suggestive remarks or advances made by me or you will result in immediate termination of the

session, and I or you will be liable for payment for the full scheduled session.

My session may be abbreviated if I did not arrive at scheduled time

Client Signature:____________________________________________________________________________________________Date:__________

Therapist Signature:_________________________________________________________________________________________Date:__________

Confidential Client Information Form

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