Name
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First Name
Last Name
Date of Birth
MM
DD
YYYY
Occupation
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
Emergency Contact
First Name
Last Name
EC Phone
(###)
###
####
How did you hear about me?
Referred by
Google Search
Word of Mouth
Facebook
Other
Have you had a professional massage before?
If yes, when was your last massage?
MM
DD
YYYY
Please state any specific goal you have for your massage treatment (i.e relaxation, decrease pain, increase flexibility):
Preferred depth of pressure:
Light
Medium
Deep
Depends where
Not sure
Please list any areas that you would prefer not to be massaged (i.e. feet, scalp, face, abdomen, glutes, etc.):
Please list any areas of the body where you are currently experiencing pain or discomfort (i.e. left shoulder, right hip):
Please describe your pain/discomfort (onset, severity, frequency, movements that cause aggravation, etc.):
Please list any broken bones, fractures, sprains, strains, injuries, or surgeries within the last 5 years?
Please list any medications that you are currently taking:
Are you currently under the care of a physician, chiropractor or physical therapist?
If YES, please explain:
Has this medical condition ever applied to you in the past or present? Skin Conditions
Has this medical condition ever applied to you in the past or present? Cancer/Chemotherapy
Has this medical condition ever applied to you in the past or present? Blood Clots
Has this medical condition ever applied to you in the past or present? Cardiovascular Disease
Has this medical condition ever applied to you in the past or present? High/Low BP
Has this medical condition ever applied to you in the past or present? Herniated/Bulging Discs
Has this medical condition ever applied to you in the past or present? Rheumatoid Arthritis
Has this medical condition ever applied to you in the past or present? Scoliosis
Has this medical condition ever applied to you in the past or present? TMJ
Has this medical condition ever applied to you in the past or present? Depression/Anxiety
Has this medical condition ever applied to you in the past or present? Pregnancy
Has this medical condition ever applied to you in the past or present? Allergies to scents, oils, etc.
Has this medical condition every applied to you in the past or present? Neuropathy ("pins/needles")
Has this medical condition ever applied to you in the past or present? Hypermobility
Has this medical condition ever applied to you in the past or present? Whiplash/MVA
Has this medical condition ever applied to you in the past or present? Headaches/Migranes
Has this medical condition ever applied to you in the past or present? Osteoporosis
Has this medical condition ever applied to you in the past or present? Sciatica
Has this medical condition ever applied to you in the past or present? Spinal Fusions
Has this medical condition ever applied to you in the past or present? Firbromyalgia
Has this medical condition ever applied to you in the past or present? Bursitis/Tendonitis
Has this medical condition ever applied to you in the past or present? Plantar Fasciitis
Has this medical condition ever applied to you in the past or present? Carpal Tunnel or Thoracic Outlet Syndrome
Has this medical condition ever applied to you in the past or present? Chronic Muscle/Joint Pain
Has this medical condition ever applied to you in the past or present? Lyme
Has this medical condition every applied to you in the past or present? Diabetes
Please provide further explanation of any conditions you checked AND describe any other relevant medical issues:
Please share any other information (concerns, preferences, musical tastes, etc.) that could help me make your massage more comfortable/therapeutic for you:
Informed Consent for Treatment: Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly I agree to notify the therapist of any changes to my health. If I experience any pain/discomfort or would like the pressure adjusted during a session, I agree to inform the therapist immediately. I understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, or to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I understand that massage therapy is non-sexual in nature and any inappropriate advance made will terminate the massage. I understand that payment for service is due and payable at the time of visit. If I am unable to make a scheduled appointment, I agree to cancel within 24 hours, unless I have an emergency. If I miss a scheduled appointment without giving 24 hours notice, I agree to pay for the full cost of the missed session. I understand that if I arrive late for an appointment, the session will end at the original scheduled time to prevent penalizing another client. It is my choice to receive massage therapy and I give consent to receive treatment.
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Please check box below to sign and give your consent for treatment.