Address City State Zip. Home # Work # Cell # Occupation. Hobbies: Primary Care Physician Phone. Address City State Zip

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1 CLIENT INFORMATION Client s Name HEALTH INFORMATION Today s Date Male Female Date of Birth Age Marital Status: Single Married Widow(er) Divorced Separated Home # Work # Cell # Occupation Hobbies: Primary Care Physician Phone Are you currently under the care of a physician? Yes No If so, for what? Current operations, accidents, broken bones or injuries: How did you hear about the company? Who is responsible for payment? IN CASE OF EMERGENCY Name Phone Relationship INSURANCE INFORMATION Name of Insured Date of Birth Employer Card Holder SS# Contract # Group # Primary Insurance Company Phone Name of Insured Date of Birth Employer Card Holder SS# Contract # Group # Secondary Insurance Company Phone Elements of Thyme, LLC Massage & Wellness Lauren Kiley, CMT Phone (908) CustServ@ElementsofThyme.com

2 REASON FOR TODAY S VISIT Have you had massage therapy before? Yes No If so, when & by whom? What is your level of stress? Low Moderate High What is your major area of pain or concern? When did you first notice it? What brought it on? Since the time your pain or concern began, has it: Stayed the Same Become Worse Improved How would you rate your pain on a scale from 0 (No Pain) to 10 (Worst Pain Possible)? How would you describe your pain No Pain? Comes/Goes? Sharp? Dull? Aching? Burning? Radiating? Stabbing? Numb? Tingling? Superficial? Deep? Other What activities aggravate it? Does it interfere with Work? Sleep? Recreation? What have you done to get relief? What do you believe is wrong with you? Has there been a medical diagnosis? Yes No By whom? Name of Physician Phone What was the diagnosis? What tests were done? Exam Blood work X-rays MRI Other Have you ever had similar problems before? Yes No When? What caused those episodes and what was the previous diagnosis? What was the treatment? What relieved it? HEALTH HISTORY Please CIRCLE the conditions or symptoms you are currently having difficulty with & UNDERLINE the symptoms you have had problems with in the past. General Symptoms Thyroid Imbalance High Cholesterol Epilepsy Fever; Rheumatic fever Bodily heaviness Diabetes Tremors Cancer Weight loss/gain Hypo/Hyperglycemia Anemia Hepatitis Sudden energy drop Cold/Night Sweats Lyme Disease T.B Loss/Poor Balance Kidney Disease Asthma AIDS Peculiar tastes/smells Liver/Gall Bladder Disease Emphysema Reynaud s Disease Bleed/Bruise easily Gastritis/Pancreatitis Ulcer Alcoholism Chronic Pain Condition Stroke IBS/Diverticulitis Poor/loss of memory Skin and Hair Rashes Ulcerations Hives/allergic Dermatitis Itching Eczema/Psoriasis Dandruff Loss of hair Recent moles Skin discoloration Acne Change in texture Face flushing Dermatitis Warts Fungal Infections 2 H ealth Information

3 HEALTH HISTORY (continued) Head, Eyes, Ears, Nose, Throat and Mouth Eye Strain Light Bothers Eyes Migraines Sores on lips/tongue Eye Pain Ringing in Ears Headaches Nose bleeds Color Blindness Poor Hearing Head feels heavy Sinus problems Cataracts Earaches Difficulty swallowing Facial Pain/Twitching Blurred/Poor Vision Recurrent sore throats/cold Grinding teeth Wear Glasses/Contacts Spots in front of eyes Dental/Gum Problems Jaw Clicks/Locks Cardiovascular Chest pain or pressure Heart attack Varicose/Spider Veins Blood clots High Blood Pressure Swelling of Hands/feet Sweat Easily/Excessive Pressure in chest Low Blood Pressure Cold Hands or Feet Spontaneous Sweating Dizziness Irregular heart beat Phlebitis Palpations Fainting Respiratory Cough/Wheezing Asthma Bronchitis Production of phlegm Pneumonia Hay Fever Difficult inhale/exhale Shortness of Breath Pain with deep inhalation Tight sensation in chest Difficult breathing laying down Gastrointestinal Nausea Vomiting Acid reflux/gerd Abdominal Pain/Cramps Gas Belching Significant thirst Indigestion Bad Breath Diarrhea Bloating/Edema Chronic laxative use Constipation Urinary Pain on urination Urgent urination Urinary tract infection Night urination Unable to hold urine Burning during urination Frequent urination Kidney Stones Scanty/Copious urine flow Reproductive Pain in testicles Ovarian Cysts Menopausal Problems/Hot flashes Prostatitis Endometriosis Vaginal Discharge Uterine Fibroids Are you presently pregnant? Yes No Infertility Fibrocystic breast tissue Number of Pregnancies Irregular Menses Polycystic Ovarian Syndrome Are you presently taking birth control? Yes No Prolonged Menses PMS What type? Excessive/Scanty Menses Painful menstruation/cramps How Long? Musculoskeletal Neck pain/spasms Herniated/Bulging Disk Hand/wrist pain Tendonitis Shoulder pain Sciatica Foot/ankle pain Painful joints Rotator cuff pain/problems Knee pain Muscle weakness/fatigue Limited range of motion Hip pain Arthritis Muscle pain Bursitis Back pain Carpal tunnel Sprains/Strains Neuro/Psychological Seizures Sciatica Depression Currently Seeing a therapist Lack of coordination Anxiety/Panic Attacks Seasonal Affective Disorder Areas of Numbness Nervousness Bad temper/irritable Pins & Needles Easily stressed ADD/ADHD Please list any serious medical conditions or elaborate on any of the above: 3 H ealth Information

4 Please list hyposensitive or allergies to chemical, environmental, food, drugs, etc.: Previous operations, accidents, broken bones or injuries: ENERGY, LIFESTYLE & NUTRITION Describe your level of Energy: What time of day is your energy: Lowest? Highest? Do you fatigue easily? Yes No What makes you tired? Describe your typical sleep pattern: How many hours per night? Type of Mattress: Pillow top Tempur-pedic Sleep Number Waterbed Comfortable Uncomfortable (please circle) Age of Mattress What kind of pillow do you use? Foam Down Do you sleep on your Side? Back? Stomach? Exercise: Days per week Length of workout Type of Activity Do you wear? Heel lifts Sole supports Arch supports Inner soles Are you taking any? Aspirin Sedatives Sleeping Pills Insulin Blood Thinners Birth Control Vitamins Minerals Herbs Laxatives Other: Medications (List them & Dosages) How many meals do you eat a day? Typical Diet: Breakfast Lunch Dinner Snacks Snacks Snacks Appetite: Poor Heavy (please circle) Changes in Appetite: Describe your Cravings: Strongly like: Cold Drinks Hot Drinks (please circle) How much water do you drink a day? Caffeinated Drinks (what/how many) Alcohol per week 4 H ealth Information

5 Indicate the following habits with: (H) Heavy (M) Moderate (L) Light (N) None Coffee Tea Colas Alcohol Meat Dairy Sugar Sugar Substitutes White flour Tobacco How many bowel movements per day? Are you currently constipated? Yes No PAIN CHART Identify your painful areas on these drawings using an X or SHADING. HEALTH INFORMATION/CLIENT CONSENT The above information is accurate to the best of my knowledge and I freely give permission to be massaged. I agree to inform the therapist of any experience of pain during the session. I understand this does not and should not deter me from seeking medical treatment for medical conditions. I understand that it may be necessary to obtain permission from my healthcare provider, to receive or continue therapy. I agree to update the massage therapist in regard to changes in my health and understand that there shall be no liability on the part of Elements of Thyme, LLC and/or the therapist should I forget to do so. Client s Name Printed: Client s Signature: Date: If the client is a minor, he or she has been informed of the above statements in the presence his/her guardian. Guardian s Name Printed: Guardian s Signature Date: 5 H ealth Information