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Birth Date*

Primary Phone*

Secondary Phone

Email Address*

Preferred Method of Contact (Please choose One)*

Occupation *

Referred By

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, ect.?*

If yes, please describe

Check all activities that apply to you*

Do you have stress in your work, family, or other aspects of your life?*

If yes, please describe

Have you had any recent accidents, injuries or surgeries (in the past 6 months)?*

If yes, please describe

Do you have any allergies/sensitivities to oils, lotions or scents? *

If yes, please describe

Please list any current medications (prescription and over the counter) or supplements you take and what they are treating. **LIST NONE, IF YOU DON'T TAKE ANYTHING.***

Do you have experience with Essential oils?

Health History


Musculoskeletal System*

Circulatory System*

Nervous System*


Respiratory System *

Skin *

Digestive System*



Any other medical conditions not listed above

Waiver of Liability and Consent to have Massage*

Cancellation Policy*

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