First Name *

Last Name *

Occupation *

Date of birth *

Email *

Phone *

Address *

City *

State *

Postal code *

Emergency Contact *

Emergency Contact Phone *

Family Doctor

Family Doctor Phone (if known)

Family Doctor Email (if known)

The following information will be used to help plan safe and effective massage therapy sessions. Please answer the questions to the best of your knowledge.

Date of Initial Visit

Have you had a professional massage before? *

Yes

If yes, how often do you receive massage therapy?

Type of massage experienced? ( Swedish, Shiatsu, Deep Tissue, etc.

Do you have any difficulty lying on your front, back, or side?

Yes

If yes, please explain: *

Do you have any allergies to oils, lotions, or ointments? *

Yes

If yes, please explain:

Do you have sensitive skin?

YES

Are you wearing (check all that apply)

Contact Lenses

Dentures

Hearing Aid

Hairpiece

Do you sit for long hours at a workstation, computer, or driving?

YES

If yes, please describe:

Do you perform any repetitive movement in your work, sports, or hobby?

YES

If yes, please describe:

Do you experience stress in your work, family, or other aspect of your life?

YES

Other, please explain:

Is there a particular area of the body where you are experiencing tension, stiffness, pain, or other discomfort?

YES

If yes, please identify:

List all previous surgeries, illnesses and injuries (including Motor Vehicle Accidents) *

Are you currently taking any medications?

YES

If yes, please list name and reason for medications:

Are you currently seeing a healthcare professional?

YES

If yes, please list name(s) and reason/treatment:

What are your goals/expectations for this therapy session?

The following sometimes occurs during massage. They are normal responses to relaxation. Trust your body to express what it needs to:

-needs to move or change position

-sighing, yawning, change in breathing

-stomach gurgling

-emotional feelings and/or expression

-movement of intestinal gas

-energy shifts

-falling asleep

-memories

Do you get 8 hours of sleep each night? *

Yes

Mostly

Do you have good eating habits? *

Yes

Mostly

Do you have any symptoms of COVID-19? If yes, please contact us for further details. *

Yes

Notes

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.