| Massage & Wellness Therapy |
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| Sharon Kennington |
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| Today's Date: ________________ | Client History | |
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Name ______________________________________ Date of birth ____________ Address ____________________________________ Phone (day) _____________ City/Zip _____________________________________ Phone (eve) ____________ Occupation(s) _______________________________________________________ Email address: _______________________________________________________ Who referred you? ___________________________________________________ Interest(s) __________________________________________________________ Is there any area where you hold a lot of tension?_____________________________ Previous experience with professional massage? None Occasional Regular Do you prefer Light Moderate Deep massage pressure? Are you cold natured moderate hot natured? Are you right-handed left-handed? Daily exercise? None Occasionally Regularly Posture assumed most of day Sitting, Standing, Varied? Medical History: |
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| ___ Abscess or open sore | ___ Fibromyalgia | ___ PMS/painful menstruation |
| ___ Allergies | ___ Headaches | ___ Poor Circulation |
| ___ Anemia | ___ Heart Problems | ___ Pregnancy |
| ___ Arthritis | ___ Herniated disc | ___ Rheumatoid arthritis |
| ___ Bursitis | ___ High Blood Pressure | ___ Sciatica |
| ___ Cancer/Malignancy | ___ Joint Problems | ___ Skin sensitivity |
| ___ Diabetes | ___ Low Blood Pressure | ___ Spinal Curvature Problem |
| ___ Easy bruising | ___ Osteoarthritis | ___ Varicose veins |
| ___ Epilepsy | ___ Osteoporosis | ___ Other |
| ___ Fatigue | ___ Phlebitis |
Surgery/fractures (explain & Date) ________________________________________________________
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Medications _________________________________________________________________________
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History (Car Accidents & year, Medical Condition, etc) ________________________________________
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Are there specific aspects of your life that are particularly stressful? (job, posture, habits, diet, family, etc)?
(explain) ____________________________________________________________________________
Name of Physician ______________________________ Phone _________________________________
Signature _____________________________________ Date __________________________________