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Benefits, Contraindictions, Screening, Techniques, and Special Considerations for the Massage Practitioner

1.

Client Health Record

First Name*
 Last Name*
Company
Address*
City*
State*
Postal Code*
 Country*
Email*
Day Phone*
 Evening Phone

Date of Birth:

In case of emergency:

Telephone:
2. General & Medical Information

Occupation:

Height:

Weight:


Are you basically in good health

Has there been any change to your health in the past year?

If so, please explain:

Physician:

Telephone:
If you answer "yes" to any of the following questions, please explain as clearly as possible.

Check all that apply

Specify:


if yes, what medication are you taking?








Please explain:



Please explain:

Do you have any other medical condition I should know about?

Are you taking any medications (including non-prescription drugs)







Are you using any of the following products?




Your health

How much water do you drink a day?

Glasses

Do you exercise regularly?

How would you describe your overall level of stress?


Comments:

Terms and Conditions

I agree that the information I provided is correct to the best of my knowledge and agree to the terms and conditions of thenaturalhealthspa.com.

I have read and accept these terms and conditions.


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