Parent/Guardian's Email Address*
Child's Primary Care Physician, Clinic Name & Phone Number*
Has child ever received professional massage?*
Reason for seeking massage therapy*
In order to better address your child's goals, please state your/your child's specific concerns and approximate date of onset *
Has child tried any other treatments for concerns listed above?*
Was child born prematurely?*
If yes, how many weeks early?
Were there any postpartum complications with the child?*
Please list any current medications (prescribed and over the counter) or supplements the child is taking and what they are treating. Put 'none' if not taking anything.*
Has the child been diagnosed or treated for any of the following disorders/conditions? Please check ALL that apply.*
Any other medical conditions/concerns not listed above*
Has the child had any accidents, injuries or surgeries in the past 6 months?*
Does the child have any allergies/sensitivities to oils, lotions or scents?*
Please list your child's communication style *
What methods does your child use to manage stressful situations (i.e. self-soothing techniques)?*
Does your child exercise or participate in sports? *
Wavier of Liability and Consent to have Massage*
