Personal Information
Name
(Required)
First
Phone (Day)
Phone (Evening)
Address
(Required)
Street Address
City/State/Zip
Date
(Required)
MM slash DD slash YYYY
Occupation
Employer
Email
Primary Physician
Emergency Contact
Relationship
Phone
How did you hear about us?
Medical Information
Are you taking any medications?
Yes
No
If yes, please list name and use:
Are you currently pregnant?
Yes
No
If yes, how far along?
Any high risk factors?
Do you suffer from chronic pain?
Yes
No
If yes, please explain
What makes it better?
Grief Information
When did the loss occur?
Where do you carry your stress?
Please indicate any of the following that apply to you.
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
IG Issues
Sprains or Strains
Explain any conditions you have marked above:
Massage Information
Have you had a professional massage before?
Yes
No
What type of massage are you seeking?
Relax & Rest
Grief Massage
Others
Other
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities?
Yes
No
If Yes, please explain
Are there any areas (feet, face, abdomen, etc.) you do not want massaged?
Yes
No
If Yes, please explain
What are your goals for this treatment session?
Please circle any areas of discomfort
1
2
3
4
By signing below you agree to the following:
I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
Client Signature
Date
MM slash DD slash YYYY
Therapist Signature
Date
MM slash DD slash YYYY