Please Note there is a 24 hour cancellation policy for all appointments. 

In absence of a sudden, illness or accident, full session fee is required to reschedule your appointment.

 

Date ­­­­­­­­­­­­­­­­­­_____________                                                 Referred by ____________________________

 

Name___________________________________________            *Cell Phone _____________________

 

Address (street) ___________________________________           Work Phone ______________________ 

 

              (town)____________________________________           

 

  (state, zip) ________________________________            Date of Birth _____/____/_____

           

Email Address _________________________________________ (no spam, promise)

 

Occupation ________________________________________________________________________

 

Exercise / Sports Activities ___________________________________________________________

 

Have you ever received a Therapeutic Massage?  Yes_____ No_____ Smoker?  Yes ____   No ____

 

Was it intended for stress relief & relaxation? ____ For pain relief? ____ Both? ____

 

Reason for today’s visit _______________________________________________________________

 

List any accidents, fractures, and surgeries in the past 5 years:

 

____________________________________________________________________________________

____________________________________________________________________________________

 

List any accidents, fractures and surgeries beyond 5 years ago:

 

 

 

 

Describe any current or ongoing muscular-skeletal pain or stiffness:

 

Please list current medications you are taking: _____________________________________________________________________________

 

___________________________________________________________________________________________________________________

 

Are you allergic to aspirin? __________    

 

Allergies or sensitivity common ingredients to oils, lotions, scents?   NO ___YES (please list) _______

___________________________________________________________________________________

 

Women:  Are you Pregnant? _____    If so, how far along _____________________________

 

I am sensitive / ticklish on my feet ______ I am ticklish in general __________

 

 

Existing Conditions – Please mark with an "X"  any/all that apply now – or place a “P” for conditions experienced in the past.

 

Varicose Veins _____

​

Blood Clots ______

 

Swollen extremities ____

 

Numbness / Tingling ____

 

Herniated Disc ______

 

Sciatica _______

 

Scoliosis _______

 

Osteoporosis ______

 

Muscle Tightness______

 

Infectious Disease _____

 

Depression _____

 

Bowel Irregularities ____

 

Muscle, bone injuries ___

 

Muscle, joint injuries ___

 

TMJ, jaw pain _____ 

​

Headache _________

​

Migraine __________

 

Neck Pain   ____

 

Dizziness / fainting _____

 

Loss of Balance ____

 

Inner Ear problem _____

 

Allergies _____

 

Sinus pain/infection _____

 

Asthma ____

 

Thyroid Imbalances ____

 

Hypoglycemia ______

 

Diabetes _______

 

Cancer / Tumors ______

 

Respiratory problem ____

 

Seizures/convulsions ____

 

Immune Deficiency _____

 

Skin Sensitivity ______

 

Low Blood Pressure ____

 

High Blood Pressure ____

 

Liver Problem _____

 

Kidney Problem _____

 

Gall Bladder Problem ___

 

Bladder Problems _____

Digestive Problems _____

 

Hepatitis ______

 

Herpes ______

 

Joint Pain _____

 

Easy Bruising ______

 

Sleep Problems _____

 

Chronic Fatigue _____

 

Chronic Stress _____

 

Fibromyalgia _____

 

Lyme Disease _____

 

Arthritis / tendonitis ____                                                                                                                                                                

 

OTHER MEDICAL CONDITION NOT LISTED ___________________________________________

 

Please explain any areas noted above if you are currently seeing a doctor for that condition:

 

 ___________________________________________________________________________________________________________

 

The Information shared here and in session is treated with confidentiality.  Please give feedback at any

time during or after the massage.  This communication between you and I during the massage will

facilitate a more productive outcome from the session for you. 

 

I, the client, understand that the work done during this massage does not constitute medical treatment and that

the massage therapist is not a physician.  The session is a form of health and wellness maintenance

utilizing the techniques of massage and holistic healing.  I, the client, take responsibility for alerting the therapist

to any conditions that might affect this work.  It is recommended that I, the client, see a physician for any ailments

I might have.  Any suggestions made by the massage therapist are recommendations, not prescriptions.  I

understand and agree to the above conditions.

 

Signature:                                                                                Date: