Emergency Contact Name, Relationship to Client & Phone
Primary Physician, Clinic Name & Phone Number
How would you rate your overall health?
Have you ever received a professional massage?
Reason for seeking massage therapy
In order to better address your goals, please state your specific concerns and approximate date of onset
What is your exercise level?
Do you perform any repetitive movements in your work, hobbies, sports, etc.?
Check all activities that apply to you
Do you have stress in your work, family, or other aspects of your life?
Have you had any recent accidents, injuries or surgeries (in the past 6 months)?
Do you have any allergies/sensitivities to oils, lotions or scents?
Please list any current medications (prescription and over the counter) or supplements you take and what they are treating.
Please check ALL symptoms/conditions that apply
Any other medical conditions not listed above
Waiver of Liability and Consent to have Massage
