Your Session

What are you looking primarily for in your massage today?

Full Body Experience Precise Therapeutic attention Both

Please use the diagram below to indicate areas of tension or discomfort

I would like my massage to be more: label Smooth and Flowing..............................................Deep and Focused

1 23 45 67 89 10

My tolerance for pressure is:I am a delicated rose petal..............................................I don't feel pain

1 2 3 4 5 6 7 8 9 10

Mediacl History:Do you exercise regularly Yes No Type : Are you currently under the care of a physician? Yes No Name, phone number , and what forAre you using any medications or other substances? If yes, please list 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:

Arthritis Asthma Diabetes Blood Clots Back problems/Scolionsis Broken/Dislocated bones Bruise Easily Cancer Chemical Dependency Chronic Fatigue Chronic Pain Constipation/Diarrhea Depression, Panic Disorder, or other psych Conditions

Diverticulitis headaches heart condition hepatitis insomnia Muscle Strain/Sprain Pregnancy Seizures Skin conditions/Rash Surgery Tendonitis/Bursitis TMJ Disorder Vericose Veins Whiplash

Any Communicable Diseases?

Consent for CarePlease 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 medicalonditions 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

Proudly servicing many U.S states

Eminence Massage Therapy is an Elite Personal Care Service that uniquely brings luxurious professional pampering to your home, hotel, or office. Our mobility provides you with more convenience and a deeper sense of relaxation and comfort than traveling. We take pride in developing lasting relationships with many customers, vendors, and other professionals, therefore we always ensure excellent customer service.