Emergency Contact Name:

Emergency Contact Phone:

Is this massage for a medical condition, injury or surgery?*

Do you have a physician referral/perscription?*

Have you ever received a professional massage before?*

If yes how recently?

If yes what types of massage do you prefer?

What kind of pressure do you prefer?*

What are your goals or expected outcomes for receiving massage?*

Please list your current symptoms/or issues, in order of priority.*

Please list current medications, as some medications can effect the types of massage allowed*

Are you wearing contacts?*

Are you wearing dentures?*

Are you wearing a hairpiece?*

Are you pregnant?*

Have you had any injuries or surgeries in the past that may influence today's treatment?*

Select any of the following health conditions that you currently have (If you are unsure, please ask. Please answer honestly, as massage may not be indicated for the above conditions):*

Please indicate conditions that you have or have had in the past.*

If you indicated any condition in the previous question that you have or have had in the past. Explain in detail, including treatment received

Is there anything else I should know about how you are feeling today or about your progress or care to date?

Have you had a fever in the last 24 hours of 100°F or above?*

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*