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Date Of Birth
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
How would you rate your general health? (select one)
Have you had a professional massage before?
List current medications and the conditions they are treating.
List any major accidents or surgeries (including dates).
Please tell us about any allergies or hypersensitivities.
Reason for initial visit.
Head/Neck (select all that apply)
Headaches or migranes
Ringing in ears
Respiratory (select all that apply)
Shortness of breath
Family history of repiratory difficulties
Nervous System (select all that apply)
Sensory loss or change
Numbness or tingling
Musculoskeletal System (select all that apply)
Family history of arthritis
Pins, plates, wires, artificial joint
Reproductive (select all that apply)
Cardiovascular (select all that apply)
High blood pressure
Phlebitis, varicose veins
Chronic congestive heart failure
Low blood pressure
Family history of cardiovascular problems
Skin & Infections (select all that apply)
HIV or AIDS
Infectious skin conditions
Other Conditions (select all that apply)
Unexplained weight loss
Chronic fatigue syndrome
Other conditions (please describe)
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of the success or effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and I will
inform my practitioner of any changes in my health status.
I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing.
Terms And Conditions
I agree to the terms & conditions*
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