Name*

Date of birth*

Address*

Phone number*

Email*

Occupation*

Emergency Contact: Name and Phone#*

Referred by...*

Have you had a professional massage before?*

What type of massage and what pressure do you prefer?*

What are your goals for this session? ie. pain relief, stress relief, relaxation.*

Do you have any areas of discomfort in the body? Tension, Decreased Range of Motion, Stiffness, or pain. Rate pain level 1-10*

What makes it better or worse?*

Do you suffer from chronic pain?*

If yes, please explain. What makes it better? What makes it worse?

Have you had surgery in the last year?*

If yes, please explain when and what area.

Are you taking any medications or supplements?*

Please list name and use:*

Are you currently pregnant?*

If so, for how long? Any high risk factors?

Please indicate any condition that you currently have or have had in the past.*

Please explain any conditions you have marked above

Do you have any requests or anything else I need to know? ie. sensitive to fragrances, allergies or areas to avoid.(feet, face, abdomen, etc.)*

Do you have any areas that you want specific work or extra time on?*

Is it ok for me to work on your hips?*

I have listed all my known medical conditions and physical limitations to the best of my knowledge and I will inform my therapist of any changes in my physical health.*

I agree to communicate any time I feel like my well-being is being compromised.*

I understand and agree: 1) the bodywork I am receiving is for the purposes of pain relief, stress reduction, relaxation, improving circulation and/or relief from muscle tension;*

2) the therapist neither diagnoses illness, disease or any other medical, physical or mental disorder, nor performs any spinal manipulations;*

3) I am responsible for consulting a qualified physician for any ailment I may have.*

I understand that all services rendered are my personal responsibility and payment is due at the time of service unless prior arrangements have been made.*

Please note that a 24-hour cancellation is required or a fee will be charged.*