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Massage Client Health History Form Client Information and Release Form Name Birth Date Address City State Zip Phone Number(s) Home Work Cell E-mail Address Referred By Is this your first massage General Medical History Check the box if you have or have had recent problems with any of the following: □ □ □ □ □ □ □ □ □ Arthritis Bursitis Back Pain Neck Pain Arms / Hands (Pain) Hips / Legs / Feet (Pain) Headaches Swollen Joints Fibromyalgia □ □ □ □ □ □ □ □ □ High Blood Pressure Low Blood Pressure Poor Circulation Anemia Stroke Chest Pain Seizures / Convulsions Heart Conditions Constipation □ □ □ □ □ □ □ □ □ □ Sinus / Allergies Hematomas Phlebitis Vericose Veins Cancer Skin Conditions Pregnant of months Menstrual Pain Warts Athlete’s Feet Please circle any areas of pain, injury, tension, or restriction of movement..
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