Client Name:*

Preferred Name:

Birthday: *

Phone:*

Email:*

Address:*

City:*

State:*

Zip code:*

Occupation:

What are your goals/expected outcomes for receiving massage/bodywork?*

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

How do you feel today?*

Do these symptoms interfere with your activities of daily living ( e.g., sleep, exercise, work, childcare)?

If yes, explain

List the medications you currently take:*

Have you had any injuries or surgeries?*

Are you pregnant (yes, no, unsure) and how far along?

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 following conditions):*

Please indicate if you are experiencing or have had any of the following*

Please explain any of the above selected conditions:

Do you have any allergies, including skin sensitivities?*

Please select the type of massage therapy services or techniques that you are anticipate receiving during the session.*

Which areas of your body do you consent to have treated during your session? Please check all areas you give permission to be worked on. Any unchecked areas will not be treated.*

Anything else you wish to share?

Today's Date:*

Please write your full name below for client/guardian signature*