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Child's Name*

Child's Birth Date *

Parent/Guardian's Name*

Primary Phone *


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?*

If yes, please describe

Birth History*

Was child born prematurely?*

If yes, how many weeks early?

Were there any postpartum complications with the child?*

If yes, please describe

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?*

If yes, please describe

Does the child have any allergies/sensitivities to oils, lotions or scents?*

If yes, please describe

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? *

If yes, please describe

Wavier of Liability and Consent to have Massage*

Cancellation Policy*

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