Emergency Contact Name and Number*
Have you had a professional massage before? If yes, when?
Do you have any areas of broken skin? rash? wound? candida? toe fungus? warts?
Do you have any allergies? (nuts, oils, lotions, fruits) if yes, please list
Are you taking any medications, supplements? Please list, as well as dosage.
Please describe previous injuries, surgeries, causes and dates of occurrences. *
If applicable: Please describe any treatments you have received for these particular issues.
What would you like to address in our treatments together?*
If applicable: How long has this been an issue for you? (Please list onset date) What does it rate on a pain scale from 1-10. (10 being the worst)
Is there anything else you want to share?
The following is to get an idea of your Health History. Please check all that apply: Cardiovascular
The following is to get an idea of your Health History. Please check all that apply: Head and Neck
The following is to get an idea of your Health History. Please check all that apply: Neurological
The following is to get an idea of your Health History. Please check all that apply: Respiratory
The following is to get an idea of your Health History. Please check all that apply: Musculoskeletal/Skin
The following is to get an idea of your Health History. Please check all that apply:
Terms & Conditions: Waiver:
I understand that massage therapy is provided for stress reductions, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
Please Initial.
I understand that massage is not a substitute for medical care and that my massage therapist is not qualified to diagnose, prescribe, or treat mental illness. Please initial.
I understand that massage is entirely therapeutic and non-sexual in nature. By signing this release, I waive and release my massage therapist from any liability, past, present, and future, relating to massage therapy and bodywork. Please Intial.
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