Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Phone Number
*
(###)
###
####
Email
*
Occupation
Goals:
I'd like my massage to help me
Referred by
Are you experiencing, or do you have any of the following:
Please check all that apply
Please provide a brief description of any that apply above:
Are you taking any prescribed medications?
*
No
Yes
If yes, please list below:
Are you taking any over the counter medications or known blood thinners?
*
No
Yes
If yes, please list below:
Do you have any known allergies?
*
No
Yes
If yes, please list below:
Have you ever been diagnosed with, or been advised to seek treatment for:
Please check all that apply
Please provide a brief description of any that apply above:
Have you ever had any:
- HOSPITALIZATIONS and/or SURGERIES
- ACCIDENTS and/or INJURIES
- BROKEN and/or DISLOCATED BONES?
Have you received therapeutic massage/bodywork before?
No
Yes
Date of Last Massage
MM
DD
YYYY
Likes/Dislikes
- No abs, feet, face, etc.
- No music, scents, talking, etc.
- A lot of time spent on feet, low back, hands, etc.
What hobbies, activities, or recreation do you participate in?
Signature:
Date:
MM
DD
YYYY
