Client Health Information Sheet

Date:  Name:  Sex: Female  Male        Date of Birth: 

Address:  State:  Zip: 

Daytime Phone: Email: Occupation:

Present symptoms: What is your 
major complaint or condition 
you want to improve? 

What have you done to get relief?

What are your intentions or expectations for this visit?

Are you now under medical/therapeutic treatment? Yes  No  If yes, for what condition?


Emergency contact name/phone number/relationship: / /

Are you being prescribed blood thinners?

Please list (date and description) any accidents or operations:

Any additional comments regarding your health and wellbeing:


Informed Consent: I, (client) understand that massage therapy provided by Julianna Szabo, (massage therapist) is intended
to enhance relaxation, reduce pain caused by muscle tensions, increase range of motion and offer a positive experience of touch. I understand that
massage therapy is not a substitute for medical treatment or medications, and that it it recommended that I concurrently work with my Primary
Caregiver for any condition I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications,
and that spinal manipulations are not part of massge therapy. I have informed the massage therapist of all my known physical conditions, medical
conditions and medications, and I will keep the massage therapist updated in any changes. I understand these policies and agree to abide by them.
Date: