Massage Questionairre Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Preferred Phone Number(Required)Email(Required) Occupation(Required) Referred by:(Required)Yellow PagesInternetDrive ByFriendOtherOther: Posture assumed most of the day:(Required)SittingStandingOtherOther: Have you ever received a professional massage before?(Required)NoYesWhen: What results do you expect from your massage session? Are you pregnant?(Required)YesNoAre you under the care of a physician?(Required)YesNoName of physician: Briefly explain condition: What medications are you currently taking?Any recent surgeries or accidents?Exercise activities and frequency? List any areas of the body that require special attention: Type of Pain: Sharp Dull Spasm Pain in Motion Do you have any of the following? Arthritis Hematomas Heart problems Constipation Whiplash Headaches Varicose veins TMJ Fibromyalgia Leg pain Lower back pain Spastic Paralysis Osteoporosis Stiff neck Phlebitis Skin diseases Diabetes PMS/painful menstruation High blood pressure Bursitis Scoliosis Cancer Insomnia Aids/HIV+ Herpes Diverticulitis Epilepsy Shoulder pain Low blood pressure Allergies Specify Allergies: Are you at least 18 years of age?(Required)If you are under the age of 18, we will need parental consent. YesNoParent/Gaurdian Name(Required) First Last Parent/Guardian Contact Phone Number(Required)Signature(Required)It is my understanding that the massage therapist does not diagnose illness, disease, or any physical or mental disorders nor does the therapist prescribe medication or medical treatment. I understand that massage is not a substitute for medical treatment and that it is recommended I see a primary health care provider. I have listed all medical conditions that I am aware of and I will update my therapist of any changes. I am aware of and agree to The Healthy Touch Day Spaβs late cancellation/no show policyCommentsThis field is for validation purposes and should be left unchanged.
