VisionOfTouch visionoftouch
 
   
 
Thank you for taking the time to fill out your new client data sheet prior to your first visit.
Confidential Client Information
  * indicates required field  
* First Name Middle Initial
* Last Name
* Address
* City
State
* Zip
* Email
* Home Phone
Work Phone
Employer
Occupation
Referred By
* Date of Birth
* Reason For Visit
Is This Your First Professional massage?
How Frequently do you get a massage?
Please state any recent injuries, sugeries, accidents or medical treatments.
Medical History
please indicate any current or prior conditions you've have / had
Neck / Spine Injury High Blood Pressure Liver Ailment
Back Pain Low Blood Pressure Kidney Ailment
Sciatica / Leg Pain Skin Disorders Heart Ailment
Carpal Tunnel Infectious Disease Fibromyalgia
TMJ Syndrome Diabetes Cancer
Sports Injuries Arthritis PMS Synbdrome
Headache Cold / Flu / Fever Grief Process
Varicose Veins Pregnacy  
List any other pertinent medical history or conditions you feel we should know about.
Are you currently under a physician's care
If "Yes" whom?
If "Yes" please list reason(s)
Medications
Please list any medications taken now or that you take at regular intervals
Acknowledgement Statement
The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or examination. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health. I, also, understand that cancelled or missed appointments without 24 hours notice (medical emergencies excluded) may be charged in full for the price of the missed session.
* Please check that you have read and agree with the acknowledgement statement above.