Scribd Logo
Upload

Welcome to Scribd!

  • 50 views

    Large Print Health Form PDF PDF

    Uploaded by

    suso73
    This large print health form collects personal information including name, address, phone number, emergency contact, and how the client heard about the business. It asks whether the client has received massage before and what areas they do not want massaged. It also requests information on any surgeries, accidents, allergies, diseases, and medications. The client signs to acknowledge providing accurate medical information and agreeing to update the therapist of any changes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Large Print Health Form PDF PDF

    Uploaded by

    suso73
    50 views1 page
    This large print health form collects personal information including name, address, phone number, emergency contact, and how the client heard about the business. It asks whether the client has received massage before and what areas they do not want massaged. It also requests information on any surgeries, accidents, allergies, diseases, and medications. The client signs to acknowledge providing accurate medical information and agreeing to update the therapist of any changes.

    Original Title

    LARGE_PRINT_HEALTH_FORM_PDF_.pdf

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This large print health form collects personal information including name, address, phone number, emergency contact, and how the client heard about the business. It asks whether the client has received massage before and what areas they do not want massaged. It also requests information on any surgeries, accidents, allergies, diseases, and medications. The client signs to acknowledge providing accurate medical information and agreeing to update the therapist of any changes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    50 views1 page

    Large Print Health Form PDF PDF

    Uploaded by

    suso73
    This large print health form collects personal information including name, address, phone number, emergency contact, and how the client heard about the business. It asks whether the client has received massage before and what areas they do not want massaged. It also requests information on any surgeries, accidents, allergies, diseases, and medications. The client signs to acknowledge providing accurate medical information and agreeing to update the therapist of any changes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 1

    LARGE PRINT HEALTH FORM

    Name: __________________________________ DOB: ___________


    Address: ______________________State: _______ Zip: _________
    Phone: (Home) ______________________ (Work) ________________
    Emergency Contact: ______________
    Phone: ____________________
    How did you hear about this place:
    ____________________________
    *Have you received a professional
    massage before? _____

    *Are there any areas of your body


    that you do not want massaged:
    (Face) (Scalp) (Neck) (Upper Chest) (Shoulders)
    (Stomach) (Upper back) (Mid back) (Lower back)
    (Arms) (Hands) (Gluteals) (Legs) (Feet)

    *Please list any surgeries you have had in


    the past________________________
    ______________________________
    *Please list any accidents you have had in the
    past_____________________________________________________
    ________________________________________________________
    *Please list any allergies you have_______________________________
    *Please list any diseases you have_______________________________
    *List any medications you are currently on? ________________________
    ________________________________________________________
    *Is there anything else I should know about________________________
    ________________________________________________________
    I have stated all conditions that I am aware of and that this information is true and
    accurate to the best of my knowledge. I agree to inform my massage therapist immediately of
    any change in conditions as stated above. I acknowledge that this information is confidential and
    intended for review by fellow massage therapists; that a medical referral may be requested of
    me; and that This place of business is not held liable for the management or arising of
    conditions.

    Signature: _______________________________ Date: _______________

    You might also like