Desired Massage Therapist
Desired Massage Schedule
Desired Days
Desired Times
Name
Age
Address
Email
Cell Phone
Emergency Contact Name
Emergency Contact Phone Number
Have you had a professional massage before?
If yes, how often do you receive massage therapy?
Do you have any allergies to oils, lotions?
If yes, please explain
Do you sit for long hours at a workstation, computer, or driving?
If yes, please describe
Do you perform any repetitive movement in your work, sports, or hobby?
Do you experience stress in your work, family, or other aspect of your life?
Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?
If yes, please identify
Do you have any particular goals in mind for this massage session?
Are you currently under medical supervision?
Do you see a chiropractor?
If yes, how often?
Are you currently taking any medication?
If yes, please list
Please check any condition listed below that applies to you:
Please explain any condition that you have marked above
Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
