Client Information Form

RENEE'S MASSOTHERAPY

Client Information Form
Name

First Name Last Name
Birthdate

Month Day Year
Date
Email Address
example@example.com
Phone Number

Area Code Phone Number
Address

Street Address

City State

Zip Code
In Case of Emergency

First Name Last Name
Phone

Area Code Phone Number
Occupation:
How did you hear about us?
Are you basically in good health?

Yes No
Do you exercise regularly?

Yes No
How would you describe your overall level of stress?

Low Medium High
Current Medication(s)?
Surgical Procedures?
If you answer "yes" to any of the following questions, please explain as clearly as possible.
Medical Conditions

Allergies Arthritis Asthma Carpal Tunnel TMJ Pacemaker Heart Disease High Blood Pressure Diabetes Pregnant Poor Circulation Varicose Veins
Medical Conditions

Dizziness Fatigue Insomnia Headaches Upper back pain Neck pain/stiffness Sciatica Lower Back Pain Spasms/Cramps Sprains/Strains Sinus Problems Contagious Disease
Comments/Concerns
Late Arrivals:

Appointments are scheduled and billed by the reserved length of time. The length of your appointment will be reduced by late arrival.
Cancellations:

This time has been reserved for you. If you need to cancel an appointment, please do so at least 24 hours in advance. You will be charged for your missed appointment.
Signature

Clear
Date

Month Day Year
Date
If under the age of 18, please have Parent/Guardian sign

Clear
Should be Empty:

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RENEE'S MASSOTHERAPY