Pre-Massage Form

Pre-Massage Form

Required *

Client's Full Name *

Please specify your first & last name

Date of Birth *

Please specify your date of birth

Sex *

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Address *

Please specify your address

City *

Please specify your city

State *

Please specify your state

Zip *

Please specify your zipcode

Telephone *

Please specify your telephone

Email *

Please specify your email

Occupation *

Please fill in your occupation

How did you hear about us? *

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If INTERNET, do you recall which website?

If another client, please share their name so we may credit them

Desired pressure level please choose one *

Light
Medium
Deep
Extremely Deep

Please fill in your desired pressure level

Do you bruise easily?

Yes
No

Are you aware of any allergies including oil, lotions or nuts? *

Yes
No

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Do you generally prefer talking during massage? *

Yes
No

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Are you pregnant *

Yes
No

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Do you have diabetes?

Yes
No

Have you had any broken bones in the past two years?

Yes
No

Do you experience frequent headaches?

Yes
No

Have you been in an accident or suffered any injuries in the past two years?

Yes
No

Do you suffer from arthritis ?

Yes
No

Are you wearing Contact lenses?

Yes
No

Are you wearing dentures?

Yes
No

Do you have high blood pressure?

Yes
No

Do you suffer from epilepsy or seizueres?

Yes
No

Do you suffer from joint swelling?

Yes
No

Do you have varicose veins?

Yes
No

Do you have contagious diseases?

Yes
No

Do you have Osteoporosis?

Yes
No

Do you have any allergies?

Yes
No

Do you have cardiac or circulatory problems?

Yes
No

Do you suffer from back pain?

Yes
No

Do you have numbness or stabbing pains anywhere?

Yes
No

Are you very sensitive to touch or pressure in any area?

Yes
No

Have You ever had surgery? explain below

Yes
No

Do you have any other medical condition or are you taking any medications i should know about?

Yes
No

Comments

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that the pressure and / or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, or prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

I agree for terms and condition *

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