Personal Information
Name ______________
Phone____________
Address _________________ City/State/Zip ______________ DOB _____
Occupation ___________________ Employer ____________________
Email _____________________ Primary Physician __________________
Emergency Contact ________________ Relationship ________ Phone _________
How did you hear about us?-------------------------------------
Medical Information
Are you taking any medications?
D yes
□
Massage Information
no
If yes, please list name and use: __________
Have you had a professional massage before? Dyes Dno
What type of massage are you seeking?
D Relaxation
Are you currently pregnant?
D yes
□
no
If yes, how far along?______________
Any high risk factors?______________
Do you suffer from chronic pain?
D yes
□
no
If yes, please explain ______________
What makes it better?_____________
What makes it worse?_____________
Have you had any orthopedic injuries?
D yes
□
no
Other
□
Therapeutic/Deep Tissue
-------------------
What pressure do you prefer?
□ Light
□ Medium
Do you have any allergies or sensitivities?
□ Deep
Dyes Dno
Please explain _______________
Are there any areas (feet, face, abdomen, etc.) you do not
want massaged? Dyes Dno
Please explain ______________
What are your goals for this treatment session?
Please circle any areas of discomfort
If yes, please list: _______________
Please indicate any of the following that apply to you.
□ Cancer
□ Headaches/Migraines
□ Arthritis
□ Diabetes
□ Joint Replacement(s)
D High/Low Blood Pressure
Neuropathy
□
D
Fibromyalgia
□ Stroke
□ Heart Attack
□ Kidney Dysfunction
□ Blood Clots
□ Numbness
□ Sprains or Strains
Explain any conditions you have marked above:
By signing below you agree to the following.
I have completed this form to the best of my ability and
knowledge and agree to inform my therapist if any of the above
information changes at any time.
Client Signature ____________ Date _____
Therapist Signature ___________ Date _____