NEW CLIENTS or if you haven't seen Jennifer since before May 1, 2015.

Health History


Please fill out this Health History and submit. All clients must fill out a Health History prior to their first massage. This will save time that may take up your appointment time during your first visit.

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Health History Form

An accurate health history is important to ensure that it is safe for you to receive massage therapy. If your health status chances in the future, please let me know. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information. For full details, please read our Privacy Policy.

Contact Information

*Required boxes are Pink

Medical History

How do you rate your General Health?

Please check of any conditions you are experiencing or have experienced

Respiratory:
Is there a family history of any of the above?
Cardiovascular:
Is there a family history of any of the above?
Head / Neck
Infections:
Other Conditions:
Is there a family history of arthritis?
Soft Tissue or Joint Discomfort:
Surgeries or Injuries
Of Special Note:
Are you currently or previously seeing:
Other Medical Condition not listed above:
I hereby claim that the following is true and I give my consent to Massage Therapy Treatment.
I have read and agree to the terms of our Privacy Policy