A Keys Massage
Keys to Unlocking a Balanced Pain-Free You

Client Health History Form


A Keys Massage                                         Intake Form                       

Alicia N Keys LMT #15489

Client Information

Client Name ____________________________Date___________DOB___________


Occupation___________________ Cell____________ Other Phone______________

 E-mail_________________Emergency Contact_____________   Phone___________

General Heath Information


What are typical activities (things that cause stiffness or pain)? ____________________________________________________________________


What substances are you taken (medications, supplements, herbs, alcohol, ect.)? ___


What are you current massage goals? _______________________________________

 Are there any areas you wish you avoid (abdomen, buttocks, etc.)? ____________________________________________________


Current Area(s) of Pain or Stiffness/Area(s) of Focus


Area #1 _________________Severity of pain/stiffness (1-10)____ Frequency_________

Duration of pain/stiffness?__________What makes pain/stiffness worse?_____________


Area #2 _________________Severity of pain/stiffness (1-10)____ Frequency_________

Duration of pain/stiffness__________What makes pain/stiffness worse?_____________


Medical History Please include types, approximate date and treatment received



Major Illness(s)___________________________________________________________


Health Concerns                             Comments


Pain   Numbness   Altered Sensations    Fatigue    Headaches   __________________


Sleep Disturbances    Infections     Swelling      Allergies           ___________________


Skin Conditions     Head Injury    Depression     Thyroid            ___________________


Stroke    Anxiety    Diabetes    Gastric Reflex     Ulcers            ____________________


Kidney Stones    Gas   Bowel Problems   Bladder Problems       ___________________


Urinary Tract Problems       Cancer          Other                          __________________


Cardio. & Repertory


Anemia     Arteriosclerosis     Blood Cots   Varicose Veins               __________________


Phlebitis    Hypertension      Asthma     Hart Attack                   ___________________


Heart Disease Angina   Congestive Hart Failure   Other            ___________________


Muscle & Joint Specific


Arthritis   Osteoporosis    Scoliosis    Strains    Sprains              __________________


Fractures   Bursitis   Tendonitis    Disk Problems   Other           ___________________


Policies/ Consent for Treatment


Late/cancellation fees:  Late fees of $15 will be imposed if client is 15+ minutes late and will have the possibility of being rescheduled. If the practitioner is 15+ minutes late the client will receive a $15 discount w/the option to reschedule. If the client fails to give a least 12 Hrs notice to cancel an appointment client will be billed 50% of the cost of the treatment. If the practitioner late cancels client will receive 50% off their next treatment.


Sexual Harassment: Is grounds for immediate termination of treatment w/ full payment for treatment(s) scheduled required. Some example are:  improperly touching self or practitioner, client undraping self, sexual comments/questions, improper use of table, etc.


Consent for Treatment: I verify that all the information provided is correct and current to the best of my knowledge I have been informed of possible after affects of treatment(s) being given and fully consent to receive treatment at this time.




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