Massage Form. Name * First Name Last Name Email * Date Of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Health & Wellbeing How do you rate your current health and wellbeing? * Great Good Average Struggling / Need help Are you taking any medication? Yes / No * Yes No If yes please list name and use Are you currently Pregnant * Yes No Do you have any problems or issues with your body now, or recently? If so, describe history of illness * Do you suffer from chronic pain? * Yes No If yes please explain What makes it better and what makes it worse? Do you any of the following apply to you? * Cancer Headaches / Migraines Arthritis Joint replacements Diabetes High or Low blood pressure Neuropothy Stroke Heart attack Recent surgery or recent physical injury Blood clots Numbness Sprains or strains Kidney disfunction None of these apply to me If yes to any of the above, please explain further: Have you had a professional massage before? * Yes No What type of massage are you seeking? * Relaxing Therapeutic / Deep tissue Do you have any allergies or sensitivities? Yes No What are your goals for this treatment? * By acknowledging below I agree that the above information is correct and true & If anything changes I will inform my therapist Yes or No * Yes No Todays Date * MM DD YYYY Thank you.
