Client Form

Date /Time : ________ /______ Rate:__________

Surname __________________________ First Name __________________________ M.I ___________

Address ______________________________________________________________________________

____________________________________________________________________________________

Date of Birth __________________ Place of Birth __________________________ Age______________

Gender _____________________ Mobile # _____________________ Tel #: __________________

Civil Status: _______________ Nationality: ___________________ Occupation: ___________________

Medical Assessment

Weight :_______________________ Height: __________________________

Temperature: ___________________ Blood Type: ______________________

Pulse Rate: ____________________ Respiratory Rate :__________________

Medication / Medical History

Please Provide details name and length of used of my medication you are currently on, or have
previously been on for any of the following: psychiatric disorders, migraines, weight loss , epilepsy
asthma, or breathing of hormones. Please provide details regarding any other illness or problems,
mostly allergies.

Currently: _____________ Previously: _________________

Family Medical History: __________________ Given Message (modalities): _________________

Comment from the client

Work ________________________________________________________________________________

Attitude ______________________________________________________________________________

I have provided all related medical information. I understand that the purpose of this message is for
relaxation only. I understand that the message therapist will not provide medical diagnosis.

_________________________ ________________________________

Signature of Client Name / Signature of Therapist