Bodyworks Massage Therapy

Client Information

Name_______________________________________________Date____________________________

Address_____________________________________________________________________________

Phone___________________Email______________________________Date of Birth______________

Occupation_____________________________Employer_____________________________________

Notify In Case Of Emergency________________________________Phone_______________________

Whom May We Thank For Referring You?__________________________________________________

Are You Pregnant?__________If Yes, Aprox. Due Date_______________________________________

Reason For Today's Visit_______________________________________________________________

Current Illnesses/Injuries______________________________________________________________

Recent Surgeris/Fractures______________________________________________________________

Musculoskeletal Pain/Stiffness (low back, neck, shoulder, etc.)_________________________________

___________________________________________________________________________________

Any Other Physical Or Emotional Difficulties_______________________________________________

___________________________________________________________________________________

Currently Under Medical Care?_______For What Condition?___________________________________

Current Medications_____________________________________________Contact Lenses_________

Previous Bodywork________How Often?_____________Practioner____________________________

Goals For Today's Session______________________________________________________________

Type of Bodywork Preferred: Swedish__________Deep Tissue_________Sports/Stretching__________

Energy Work___________Other_________________________________________________________

If at any time during your bodywork session, any type of sexually inappropriate language is used, or any type of sexual advance is made towards your massage therapist, your session will be immediately terminated, and full payment will be required.

Signature__________________________________________________Date______________________