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Sample Massage Therapy Health History Form


A brief massage therapy client agreement along with client health history record.







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Message Therapy Agreement Template

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Message Therapy Health History


Date: ____/____/______

Name:____________________________________________________________________

Address: ________________________________________________________________

City: ____________________________ State: _______ Zip: __________________

Phone: Home _________________ Work ________________ Cell ________________

Email Address: __________________________________________________________

Date of Birth: ____/____/______ Occupation: _________

Emergency Contact: _____________ Phone: _________ Relationship: ________

Referred by: ___________________________________________________________

Please list any hospitalizations, accidents, surgeries and or serious injuries that you have had with dates:

________________________________________________________________________

________________________________________________________________________

Do you currently have any chronic conditions or illness?

________________________________________________________________________

________________________________________________________________________

Are you currently being treated by a physician or health care provider? ____Yes ____ No

If yes, please explain: ________________________________________________

________________________________________________________________________

Are you currently taking any medications (including supplements and over the counter medication)? ____Yes ____ No

If yes, please explain: ________________________________________________

________________________________________________________________________

Do you have allergic reactions to oils, ointments, lotions and / or nuts? ____Yes ____ No

If yes, please explain: ________________________________________________

________________________________________________________________________

Do you wear contact lenses? ____Yes ____ No

For women: Are you currently pregnant? ____Yes ____ No (If yes, what week: _____)


Agreement

Massage therapy is not a substitute for professional medical care or counseling. I do not diagnose or prescribe medications of any kind. I may refer you to another healthcare provider if you are experiencing a condition that is contradictory to massage therapy.

All information that is shared during the massage session is held strictly confidential.

Any no-show appointments or those cancelled with less than 24 hours in advance will be charged the full fee, unless you are ill or have an emergency. If you arrive late, your session will still end at the scheduled time and thus resulting in a shorter session. All returned checks will incur a $25 late fee.

By signing below I do hereby acknowledge that the above information that I provided is complete and accurate. I stated all my known medical conditions and medications and I will inform the message therapist of any changes in my health status. I understand that the information that I provided is strictly confidential. I also understand that the scope of massage therapy practice and the policies listed above.



Signature: _______________________________________ Date: ____/____/_____








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