Name
Address
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Occupation
Emergency Contact
Phone
Date of Birth
City
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How Did You Hear About Us?
What are you looking primarily for in your massage today?
Full Body ExperiencePrecise Therapeutic AttentionBoth
Please use the number chart below to indicate level of tension of discomfort.
12345678910
Smooth and Flowing .................................................Deep and Focussed
I am a delicate rose petal .........................................I don't feel pain
Do you exercise regularly? YesNo
Type
Are you currently under the care of a physician?
YesNo
Name, Phone Number and what for?
Are you using any medication or other substances? If yes, please state below.
Please list any surgeries, accidents, or major illnesses.
Please review the following list and check those conditions that have affected your health either recently or in the past:
ArthritisAsthmaDiabetesBlood ClotsBack Problems/ScoliosisBroken/Dislocated bonesBruise EasilyCancerChemical DependencyChronic FatigueChronic PainConstipation/DiarrheaDepression,Panic Disorder, or other Psych Conditions
DiverticulitisHeadachesHeart ConditionHepatitisInsomniaMuscle Strain/SprainPregnancySeizuresSkin conditions/RashSurgeryTendonitis/BursitisTMJ DisorderVericose VeinsWhiplash
Any Communicable Diseases?
Please read the following and sign below.
1. I understand that although massage therapy can be very therapeutic, it is NOT a substitute for medical examination, diagnosis, and treatment.
2. I acknowledge that massage should not be done under certain medical conditions and I affirm that I have answered all questions pertaining to
medical conditions truthfully. I will inform my practitioner of any changes in my health status, and all-important communication from other care practitioners. 3. I understand that this is a therapeutic massage and any sexual remarks or advances will terminate the session, and I will be liable for payment of the scheduled treatment.
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage.
Client Signature
Date
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