Massage Client Form

Name*:

DOB*:

Address*:

Phone*:

Email*:

Occupation*:

Phone*:

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How did You hear about us?*

MEDICAL INFORMATION

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Are you taking any medication:
—Please choose an option—YesNo

if yes, please give details:

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Are you currenly pregnant:
—Please choose an option—YesNo

if yes, please give details:

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Are you curently under medical supervision:
—Please choose an option—YesNo
if yes, please give details:

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Do you have a history of any of the following

AllergiesAccident/InjuryArthritisAutoimmune DisorderBack/ Neck ProblemsBlood ClotsCancerDiabetesFibromyalgiaHeadachesHeart ConditionJoint PainKidney DysfunctionLow/ High Blood PressureMultiple SclerosisNumbnessShoulder ProblemsSciaticaSeizuresSprains/ StrainsStrokePregnantVaricose VeinsVertigo. Dizzinses

MESSAGE INFORMATION

Have you had a professional message before:
—Please choose an option—YesNo

Type of massage you are seeking:
—Please choose an option—RelaxationTherapeutic

What pressure do you prefer:
—Please choose an option—LightMediumFirm

Areas you don't want massaged:

By check box, I acknowledge that I am aware of the benefits and risk of message therapy and that I have completed this form to the best of my knowleade, I also agree to inform my massage theraoist of any health or medical changes.