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Health Questionnaire
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.
 

Health History
 

Head/Neck (select all that apply)
Respiratory (select all that apply)
Nervous System (select all that apply)
Musculoskeletal System (select all that apply)
Reproductive (select all that apply)
Cardiovascular (select all that apply)
Skin & Infections (select all that apply)
Other Conditions (select all that apply)

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
 

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