City____________________________ State_______ Zip__________________
Cell Phone ______________________________________________________________
Date of Birth ________________________ Male ________ Female_________
Height________________ Weight ______________ Age____________________
May we contact you by email with specials and promotions? Y/ N.
Appointment reminders are sent 2 days prior by email,1 day prior by text is this acceptable? Y/N.
Pressure Preferred Mild _________ Moderate________ Firm________
Desired results, Relaxation __________ Pain Relief_________ Increased Flexibility_________
Had massage before Y / N. last Date________________________
What kind of exercise/sports do you do
Describe any recent injuries, illnesses, broken bones, or surgical operations in the last two years .
Are you taking any medications for a heart condition or for pain management, if so what?
Please check (X) any of the conditions below that apply to you.
HEAD_____ TMJ _____ Grind Teeth
_____Head feels heavy _____Lights bother eyes
_____Ringing in ears R___ L ___
_____Loss of balance _____Headaches/
NECK / SHOULDERS
_____Stiff neck _____Pain in neck with movement
_____Can’t raise arms above shoulder
_____Can’t raise arms over head
_____Hands are cold _____Loss of grip
_____Shooting pain in arm /hands
Low back pain when, Lifting ____ Sitting _____
_____Lying down _____ Bending _____
_____Coughing _____ Getting up _____
_____Sciatica R ___ L ___
_____Leg or foot cramps _____Cold feet
_____Swollen ankles _____Ticklish feet
_____Varicose Veins R ___ L ___
_____Hip replacement R ___ L ___
_____Knee replacement R ___ L ___
____Knee(arthroscopic) surgery R ___ L ___
_____Pregnant , # Months _____
_____Post partum depression
_____Menstrual pain _____Irregular cycle
_____Nausea _____Gas _____Diarrhea
Bursitis / where ___________________________________________________________
Blood pressure high __________ low _________
Bruise easily _______ Sinus_______
_______Osteoporosis _______Shortness of breath
Seizures, convulsions, epilepsy/explain__________________________________________
Stroke or closed head injury/ explain____________________________________________
Diabetes Type 1 / 2 Insulin dependant Y/N
Infectious Disease/condition/explain ____________________________________________
Inflammation/ where ________________________________________________________
Skin condition/ rash/ where/___________________________________________________
Strain/Sprain/ Date/Where ____________________________________________________
Suggestions for getting the most benefit from your massage
If you notice yourself holding your breath, release the air from your lungs. Exhaling releases tension, holding your breath retains tension.
Exhale when your Therapist is applying pressure or stretching a muscle.
Communicate with your Therapist
Drink more water than you normally would in the 24 hours following your massage.
I understand that the massage/bodywork I receive from the massage therapist is provided for the basic purpose of relaxation and relief of muscular tension. I further understand that massage/bodywork should not be considered as a substitute for a medical examination, diagnosis, or treatment. I also understand that the massage therapist does not diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the sessions(s) given should be considered as such.
Because massage/bodywork is contraindicated (should not be performed) under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions on this form and/or asked by my therapist, honestly and completely to the best of my knowledge. If I have specific medical conditions or symptoms where massage/bodywork is contraindicated, I agree to keep my massage therapist updated in future sessions as to any changes in my medical profile. I also agree there is no liability on the massage therapist part should I fail to do so.
If I experience any pain or discomfort, during this session, I will immediately inform the therapist so their pressure, strokes, and or technique may be adjusted to my comfort level. If at any time I should feel uncomfortable with any part of the massage or the area being massaged or any other concern, I am to inform the Therapist immediately.
Any illicit or sexually suggestive behavior either physical or verbal made by me, will result in immediate termination of the session and I will be liable for the “full” scheduled appointment and that I may be reported to the appropriate authorities.
Clients Initials ___________
Client Signature________________________________ Date ____________
Therapist Signature _______________________________