client questionnaire
Last Name:____________________________ First Name:__________________________
Today's Date: ___/___/___
Home Address: ____________________________________
____________________________________
Phone (home/or cell): ___________ Phone (work): ___________ Date of Birth: ___/___/___
Height: _______ Weight:_______ Occupation:___________________________________
Posture assumed most of day (sitting? standing? leaning over? stooped?):
_________________________________________________
Please answer the following questions in as much detail as you can. If you need more
room use the back of this form.
Daily activities, sports, hobbies:
________________________________________________________________________
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Reason for today's visit? (Relaxation? Muscle Tension, etc?)
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Have you had a massage before? What did you enjoy about it?
________________________________________________________________________
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Were you referred by a doctor or health care provider? (circle one): YES NO
If YES, please explain circumstances:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Please circle any areas of tension/ pain/ discomfort in the list below:
Head/face Upper Back Buttocks
Neck Mid Back Legs
Shoulders Low Back Knees
Chest Abdomen Feet
Arms/ Hands Hips
List any areas you'd like special attention given to during the massage? (neck, feet, shoulders? Etc?):
________________________________________________________________________
Are there any areas that you would prefer NOT be massaged? (feet, face? Etc.?)
________________________________________________________________________
Please circle any items you are currently wearing:
Contact lenses Pacemaker
Dentures Hairpiece
Hearing aid Other: ___________________________
Are you experiencing any of the following today?: If yes please circle the condition:
Bruises or tendency to bruise easily Warts
Open sores or cuts Allergies or Sinus problems
Is there any chance that you are pregnant?: (circle one): YES NO
Please list medications, supplements, vitamins or other therapies you are currently using:
________________________________________________________________________
________________________________________________________________________
Do you have difficulty lying on your stomach or back for at least 30 minutes? (circle one): YES NO
Is there anything I need to know to ensure your comfort about any of the following?
(please circle, and then we will discuss):
Allergies/ sensitivities Scents
Oils/ Lotions Other:….
Medical History
Please indicate, by placing an x in the appropriate box, if you now have, or have ever had, any of the
following conditions….
Skin Conditions Musculoskeletal Conditions
Have Had Have Had
Now Previously Now Previously
Boils Fi bromyalgia
Erysipelas My ofascial
Pain Syndr ome
F ungal I nfections (Athlete's S hin S plints
F oot, ringworm, Etc.)
Herpes S prains/ Strains
Impetigo Fr actures / Brea ks
W arts Osteopor osis
Acne N/A Dislocations
Eczema Joint Pain / Stiffness
Hives Hypermo bile Joints
M oles Gout
Psoriasis Lyme Disease
Ski n Ca ncer Osteoarthritis
Respitory System Conditions R heumatoi d Arthritis
Have Had TMJ
Now Previously
Bro nchitis B unio ns
C old N/A Plantar Fascitis
I nfl uenza B ursitis
Pne umonia Hernia
Si nusitis Tendonitis
Tuberculosis W hiplash
Asthma Car pal Tunnel
C hronic Bro nchitis Herniate d Disc
Emphysema Thorasic Outlet Syndrome
L ung Cancer Reproductive System Condit ions
Chro nic Cough Have Had
Now Previously
Endocrine System Condit ions Cervical Ca ncer
Have Now Had Previously Dysme noria
Dia betes Endometriosis
Hy perthyroi dism Fibroi d Tumors
Hy pothyr oidism Breast Cancer
Hy poglycemia Ovarian Cancer
Prostate Ca ncer
Pelvic I nflammatory Disease
Pre gna ncy
PMS
Nervous System Conditions Circulato ry System Condit ions
Have Had Have Had
Now Previously Now Previously
Alzheimer's Disease Anemia
Multiple Sclerosis Em bolism/ Thr ombosis/ Bloo d Clot
(DV T)
Parki nson's P hlebitis
Peri pheral Ne uropat hy Hematoma
Tremors Hemo phelia
Meni ngitis Leukemia
Bell's Palsy Clotting or bleedi ng probl ems
Spinal Cord Injury Ane urysm
Stroke Atherosclerosis
Seizures Hy pertension ( high bloo d pressure)
He adaches Low Bloo d Pressure
Migr aine hea daches Ray naud's Syndr ome
Tension headaches Varicose Veins
Cl uster hea daches He art Disease
PMS hea daches He art Attack
Stress Heart Failure
Sleep Disorders Other H eart Co nditions
Anxiety Lymph and Immune System
Conditions
Chemical Depe nde ncy Have Had
Now Previously
De pression Edema
Eating Disorder Lymphoma
History of Mental Ill ness Mononucleosis
Digestive System Conditions Chro nic Fatigue Sy ndrome
Have Had Fever N/A
Now Previously
Indigestion HIV/AIDS
Constipatio n / Diarr hea Lupus
Chro n's Disease Epstein Barr
Refl ux Disorder Urinary System Condit ions
Stomach Ca ncer Have Had
Now Previously
Ulcers Kidney Stones
Appendicitis Renal Failur e
Colorectal Ca ncer Bladder Ca ncer
Div erticular Disease Interstitial Cystitis
Irritable Bowel Syndrome Urinary Tr act Infection (U TI)
Ulcerative C olitis
He patitis
Cirrhosis
Gallstones
Do you have now or have you previously had any cancers not listed above? Circle one: YES NO
If yes please list:
________________________________________________________________________
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Please list any past surgeries with date:
________________________________________________________________________
________________________________________________________________________
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Is there anything else I should know about your health?
________________________________________________________________________
________________________________________________________________________
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Is there anything else I should know that will make you more comfortable?
________________________________________________________________________
________________________________________________________________________
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client agreement
I understand that massage therapy provided by Blue Owl Massage therapy is non sexual.
I understand that massage therapy provided by Blue Owl Massage Therapy is for the purposes of
stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reasons
noted here if applicable:
I understand that massage therapy does not diagnose illness or disease, or any other disorder, and
that the massage therapist does not prescribe medical treatment or pharmaceuticals.
I understand it is my choice to receive massage therapy. I am aware of the benefits and risks of
massage and give my consent for massage.
I know that massage therapy is not a substitute for medical examinations or medical care, and that it
is recommended that I am concurrently working with my primary caregiver for any condition I may
have.
I have stated all of my known physical conditions, medical conditions, and medication, and I will keep
the massage therapist updated with any changes.
Signature: Date:
____________________________________________ ______________________
