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	Confidential Client Information Form 		Date: ________________________
	Name:____________________________ Home#____________________ 	Work#__________________________
Referred by:_______________________ Cell#_____________________ Email:___________________________
	Address: ______________________________________City: _____________.State:_____Zip: ______________ 
Birth date: ___/___/____ Circle  Male / Female  Marital Status ___________  # of children ______________
	Expectation for Treatment. _________________________________________________________________ 
									Circle   work / home / financial / other 
Stress Level (1-10) ___ Major Cause(s): 	_ 
Do you have any of the following today: 		                                   Please indicate your consumption: 
Tobacco 	0 	0 	0 	0 	
Alcohol 	0 	0 	0 	0 	
Caffeine	0 	0 	0 	0 	
Water 	0 	0 	0 	0 	
( filtered / tap / distilled) 			
Check & Circle										       None   Light  Moderate Heavy
other__________								
•	sunburn 
•	varicose veins / phlebitis 
•	rash / irritated skin / eczema / psoriasis 
•	edema / inflammation 
•	cold / flu
Exercise 	0 	0 	0 	0 	
•	pregnancy
•	open cuts / bruises / burns / fungus 
•		headache / nausea 
•		severe pain 
Any physical condition to prevent body positioning for given service:                                                                                              _________ 	 Allergies to oils, foods, nuts or botanicals:                                                                                                                                      ____________   Primary complaint or expectation for service: ___________________________________________________________________________                                                                                        
As a Clinical Massage Therapist and Bodyworker, I, Heather A. Harris, have been trained and qualified to handle many situations to benefit your well being. Never should it be misconstrued in any way that the session intends to provide medical treatment, to diagnose, prescribe, or perform any other service outside my scope of professional practice and licensure. 
As a professional it is my obligation to refer you, the client, to another healthcare provider equipped to handle any given needs outside my scope of practice. This may include, but not be confined to, the fields of Allopathic Medicine, Acupuncture and Oriental Medicine, Chiropractic, Dentist, Naturopathy, Dermatologist, Counselor, Physical Therapist or Podiatrist, as required by law. 
The client understands and agrees to the purpose, nature and duration of the proposed service and consents to receive the service. The Client understands that there are remote risks associated with this work and acknowledges that the provider will not be responsible for any injury arising from any unreported condition. 
The client acknowledges being given the opportunity to ask questions before receiving any work and the client has the right and responsibility to question, interrupt or stop the session. The Therapist holds the same responsibility in equal partnership. This agreement stands firmly established for all future services under law. All appointments require 24 hour cancellation, as these times are reserved exclusively, or half the service charge will be billed to the client.
	Client's Signature ____________________________________________Date_______________________________

Medical and Physical History 
	       Check              Circle Applicable 
       Past / Current
	        □        □        contact lenses / breast augmentation / other prosthesis 
       □        □        weight loss / lymph condition / swollen glands / lymph edema 
       □        □        abdominal pain / irritable bowel syndrome / constipation / ulcers
       □        □         bursitis / tendonitis / gout / osteoarthritis / rheumatoid arthritis 
       □        □        osteoporosis / hyper mobile joints / TMJ Dysfunction 
       □        □        fibromyalgia / nervous tension / anxiety attacks / asthma 
       □        □        AIDS / HIV / Lupus / Epstein Barr Syndrome / Chronic fatigue syndrome
       □        □        heart disease / stroke / phlebitis / blood clots / heart attack / arrhythmias 
       □        □        High blood pressure / Low blood pressure / diabetic / hypoglycemic 
       □        □        hormonal imbalance / menopause / menstrual problems / pregnancy __ wks. 
       □        □        Other diagnosed disease / Allergies  __________________________________________________________      
       □        □        neck pain / whiplash injury / jaw pain or tension
       □        □        Headaches- migraines, cluster, muscle contraction, fatigue, allergy 
        □        □           back pain- low or middle / disc problems _____________________________________________________
       □        □        nerve degeneration / numbness / tingling; Where? ______________________________________________
       □        □        sciatica / sacroiliac / joint ache / decreased range of motion 
       □        □        accidents; When?_____________________________________________________________________________ 
       □        □        surgery, health or cosmetic, especially recent (with in I year); When?________________________________ 
       □        □          sprains / strains / broken bones Where, When? __________________________________________________
       □        □        convulsions / seizures; Type? __________________________________________________________________
Medications: Retin-A, Sleeping pills, Hormone pills, Contraceptives, Appetite Suppressants, any Prescription, over the counter, Vitamins ( brands)_____________________________________________________________________________________
Medical Supervision: Primary Care Physician, Counselor, Dentist, Specialist _____________________________________________________________________________________________________________
As a healthcare provider, the goal strives for 100% client satisfaction, with tailored and progressive results for any treatment.                           My policy is to follow-up with your approval please indicate             ○Yes       ○ No