James Hubbard LMT

CONFIDENTIAL Client Information Form for Therapeutic Massage:

Please answer ALL questions on this form to the best of your ability, & sign where indicated.

Name______Date______DOB______Age______

Address______City ______State____ Zipcode______

Day Phone #______Night Phone #______

Preferred method of contact: CALL___TEXT___ (if text please circle # above to receive texts)

Emergency Contact______Phone #______

Referred by: ______

Primary Care Physician______Phone #______

Permission to contact your physician if needed YES___NO___ INITIALS (required)______

Have you ever received professional massage before? YES___NO___ If yes, how often? ______

Do you require assistance getting on or off the massage table? YES___NO___

Do you have allergic reactions to any oils, lotions, creams, ointments, or other solutions applied to your skin? YES__NO__ if yes please identify______

Please list current medications including over the counter meds, herbs, & vitamins: ______

______

______

Please list surgeries, include year______

______

______

Please list any accidents, include year and treatment received______

______

Please review this list & circle any illness or medical conditions which apply:

Arthritis Seizures Headaches High Blood Pressure

Blood Clots Varicose Veins Eating Disorders Numbness or Tingling

Cancer Tumors Depression Kidney/Bladder

Chronic Pain Fibromyalgia Phlebitis Painful Joints

Infectious Conditions Ruptured/ Bulging Disc Curvature of Spine Stroke: When? ______

Other: ______

It is my choice to receive therapeutic massage. I realize treatment given is for the well being of my body & mind, which includes: stress reduction, relief of muscle tension, or increase of circulation, or energy flow. I agree to communicate with my therapist if at any time I feel my well being is compromised. I give permission to receive massage to the following areas of my body: __Back; __Chest; __Abdomen; __Gluteus; __Legs; __Feet; __Arms; __Hands; __Neck; __Head; __Face.

I understand that Licensed Massage Therapists do not diagnose illness, disease, physical or mental disorders, nor do they prescribe medical treatment, medications, or perform chiropractic manipulations. I have stated all medical conditions that I am aware of, & I will update my massage therapist of any changes.

Signature ______Date ______