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Touch ‘N Go Massage Therapy
CLIENT QUESTIONNAIRE
All answers contained in this questionnaire will be kept strictly confidential.
 Name    M  
(First/MI/Last) F DOB    /  /   
 Street Address    Home Phone    
 City      State     Zip    Work Phone     
 Occupation     Email Address  
 Referred By: (Choose One)
 Website Friend Chiropractor Other
 Date of Last Massage
  / /
PERSONAL HEALTH HISTORY
 General Condition of Health?               Excellent Good Fair Poor
 Have you had any recent injuries?             Yes No    If yes, describe:
 Have you had any recent surgeries?         Yes No    If yes, describe:
 Have you had any serious illnesses?         Yes No    If yes, describe:
 Do you have any of the following medical problems?
 Heart Condition                               Yes No  Blood Clots               Yes No
 High Blood Pressure                         Yes No  Arthritis                    Yes No
 Allergies (Skin/Medication)               Yes No  Females - Could you be Pregnant? Yes No
 Varicose Veins                                Yes No  Other
 Are you medicated?                          Yes No   If yes, describe medication and when typically taken:
 Do you wear contact lenses?       Yes No
 Are you currently being treated by a Physician, Chiropractor or Other Practitioner?        Yes No
 If yes for what ailment?
HEALTH HABITS/SAFETY
The following questions are Optional and if answered will be held strictly confidential.
 Exercise: Sedentary (No exercise)
  Mild Exercise (i.e., climb stairs, walk 3 blocks, golfing)
  Occasional Vigorous Exercise (i.e., work or recreation, less than 4x/week for 30 min.)
  Regular Vigorous Exercise (i.e., work or recreation 4x/week for 30 minutes)
 Diet:  Are you dieting? Yes No
   If yes, are you on a physician prescribed medical diet? Yes No
   # of meals you eat in an average day?
   Rank Salt Intake Hi Med Low
   Rank Fat Intake Hi Med Low
 Caffeine: None Coffee Tea Cola   # of Cups/Cans Per Day?
 Tobacco:  Do you use tobacco? Yes No
  Cigarettes - Pks/day    Chew - #/day    Pipe - #/day
  Cigars - #/day            # of Years         or Year Quit
MENTAL HEALTH
 Is stress a major problem for you?                             Yes No
 Do you feel depressed on a regular basis?                   Yes No
 Do you experience panic attacks?                                Yes No
 Has your appetite or eating habits changed recently?    Yes No
 Do you have trouble getting to sleep or staying asleep? Yes No
OTHER PROBLEMS
Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.
Skin
Head/Neck
Ears
Nose
Throat
Lungs
Chest/Heart
Back
Intestinal
Bladder
Bowel
Circulation
Other
Any Recent Changes In:
Weight
Energy Level
Work Schedule
Other Pain/Discomfort:
Are there any other questions or comments you wish to discuss prior to your massage?
 

Massage Therapist Agrees:

Massage Therapist does not diagnose illness, disease or any other physical, mental or emotional disorder. As such, the massage therapist does not prescribe medical treatment(s) or medication(s), nor does she perform any spinal manipulations.

Any and all conversations during massage session related to client’s medical condition or history are kept under strict confidentiality.

Patient Agrees:

I understand that massage therapy is given for the purpose of stress reduction, relief from muscular tension or spasm, and for increasing circulation and energy flow. Massage services are designed to be a health aid and are in no way to take the place of a doctor’s care. Information exchanged during any massage session is intended to help me become more familiar and conscientious of my own health status. I agree to keep my massage therapist updated as to any changes in my client profile and understand there shall be no liability on the massage therapist’s part should I forget to do so.

Massage therapy is not a substitute for medical diagnosis or treatment and I should consult a physician for any ailments I may have. Because massage is contraindicated under certain medical conditions, I affirm that I have stated all known medical conditions and answered all questions to the best of my ability.
 
Click here if you agree to these terms.