Client Information

Full Name *

Email *

Phone *

Date of birth *

Age *

Address

Street Address *

City *

State *

Postal Code *

Emergency Contact Name *

Phone Number *

Occupation *

Referred by

How did you hear about us? (e.g. Google, Facebook, Yelp)

Health Information

Are you taking any medications? *

Yes

No

Any allergies? (oils, lotions, nuts, fruits, skin, etc) *

Yes

No

Are you pregnant? *

Yes

No

Are you currently under medical supervision or receiving other medical intervention? *

Yes

No

Do you have, or have you had, any of the following?

Areas of Swelling *

Yes

No

Diabetes *

Yes

No

Osteoporosis *

Yes

No

Autoimmune Disorder *

Yes

No

Fibromyalgia *

Yes

No

Phlebitis *

Yes

No

Back / Neck Problems *

Yes

No

Headaches *

Yes

No

Sciatica *

Yes

No

Bleeding Disorders *

Yes

No

Heart Condition *

Yes

No

Seizures *

Yes

No

Blood Clots *

Yes

No

Hypertension *

Yes

No

Stroke *

Yes

No

Bruise Easily *

Yes

No

Kidney Disease *

Yes

No

Tendinitis *

Yes

No

Bursitis *

Yes

No

Sultiple Sclerosis *

Yes

No

TMJ Disorder *

Yes

No

Cancer *

Yes

No

Neurological Condition *

Yes

No

Varicose Veins *

Yes

No

Contagious Condition *

Yes

No

Neuropathy *

Yes

No

Vertigo / Dizziness *

Yes

No

Decreased Sensation *

Yes

No

Osteoarthritis *

Yes

No

Health Information

Areas of broken skin? (e.g. rash, wounds) *

Yes

No

History of joint replacement surgery? *

Yes

No

Recent injuries or medical procedures in the past 2 years? *

Yes

No

Please describe any other injuries or health conditions: *

Massage Information

Have you had professional massage before? *

Yes

No

Reason for seeking massage? *

Relaxation

Specific problem

How much pressure do you prefer? *

Light

Medium

Firm

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

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