PERSONAL INFORMATION FORM:

First Name

Last Name

Phone *

Email *

Captcha

Address

Street Address

City

State

Country

Postal Code

Date of birth

Primary Physician

Occupation

Employer Name

Emergency Contact Name

Emergency Contact Relationship Type

Emergency Contact Phone Number

MEDICAL INFORMATION:

Are you taking any medications currently?

YES

If YES, please list the name of the medication and the reason it is used:

Are you currently pregnant?

YES

If YES, how far along are you and do you have any high risk factors?

Do you suffer from chronic pain?

YES

If YES, please explain what makes the pain better:

If YES, please explain what makes the pain worse:

Have you had any orthopedic injuries?

YES

If YES, please list the location and severity of the orthopedic injuries you have received:

Explain how any of the conditions above are currently affecting your health:

REQUIRED MASSAGE INFORMATION:

Have you had a professional massage before?

YES

What type of massage are you seeking?

RELAXATION

THERAPUTIC/DEEP TISSUE

OTHER

If you said "OTHER" above, please state the type/style of massage you are seeking:

What level of pressure do you prefer?

LIGHT

MEDIUM

DEEP

Do you have any known allergies or sensitivities?

YES

If yes, please explain what allergies or sensitivities to products/substances you are aware of:

Please list any goals you have for this treatment session:

IDENTIFY AREAS OF DISCOMFORT:

Do you have any areas of discomfort currently?

YES

If you said "YES" above, please state location and level of pain (1-10, 10 being the highest level)

Do you have any areas that you want to be "NO TOUCH"?

YES

If YES, please explain which area(s) of the body you wish to be considered "NO TOUCH":

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