Please print clearly & legibly
CLIENT NAME: ___________________
M/F D.O.B.: ______________ DATE: ______________
ADDRESS:__________________________________________
CITY/STATE/ZIP:____________________________________
CELL/ HOME PHONE: ( ) ____________ EMAIL: ________________________
PERSON TO CONTACT IN EMERGENCY: __________________________
PHONE: ( ) ______________
Were you referred by someone? If so who? ___________________
Would it be okay with you if the therapist video record the massage session? _______
Every type of massage is $60. dollars per hour, cash only up-front before the massage.
HEALTH SURVEY
The information on this questionnaire will assist the massage therapist. It will be kept in
confidence. Please check if you have had any problems with any of the following:
General Wellness is: ____ Good ____ Fair ____ Poor
Please circle any areas you DO NOT wish to have massaged:
Head/Scalp Face Neck Arms Back Stomach Buttocks Legs Feet
____ Skin Conditions/ Rash, where? _________ _____High Blood Pressure
____ Low Blood Pressure ____ Osteoporosis _____ Seizure ____Fainting
____ Dizziness _____Varicose Veins ____ Phlebitis or Blood Clot ____ Bourse Easily
_____ Heart Condition ____ Chest Pain ____ Arthritis, where ? __________
____ Shortness of Breath ____ Diabetes
Neck
____Pain with Movement ____Stiff Neck ____Popping/Grinding Noises ____Whiplash
____Recent Chiropractic treatment
Head
____Sinus/Allergies ____Headaches ____TMJ ____Grind Teeth ____Light bothersEyes ____Light headed ____Ringing in Ears
Shoulders
____Pain when Raising Arm ____Pain on Rotation ____Bursitis
Arms & Hands
____Numbness/Tingling ____Hands Cold ____Loss of grip strength ____Shooting Pain
Back
____Upper back pain ____Middle back pain ____Low back pain ____Disk Problems
____Pain when Lifting ____Pain when Sitting ____Pain when lying down ____Pain when working
Hips, Legs, & Feet
____Numbness ____Shooting Pains ____Feet Cold ____Ticklish Feet ____Hip Replacement ____Knee Surgery ____Sciatica
Medications (Aspirin, blood thinners, etc.)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Females: Are you Pregnant? ______
Abdominal Symptoms_________
Miscellaneous:
Please describe any recent illness, broken bones, injury surgery, including dental
surgery and any other conditions or information you feel we should know?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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