Emergency Contact Phone *

Is this your first professonal massage?*

If no, how frequently do you get massage?*

What do you hope to accomplish from your massage(s)?*

Are you aware of any tension holding spots in your body*

If yes, location(s)

Describe any surgeries, hospitalizations, accidents, or injuries you have had:*

What kind of care did you receive for your accidents or injuries?*

Do you feel that you have recovered from these events?

Please explain

Do you have any chronic, ongoing pain that you deal with on a regular basis?

Please explain

Describe what activities cause this pain and/or make it worse

Are you receiving any other type of medical treatment?*

Please explain*

Please list any medication (vitamins, herbs, or pharmaceutical) taken now or at regular intervals (include explanation of what medication is used to treat)*

Are you currently under the care of a physician*

Please list reasons

Are there any other health concerns you wish to discuss today?*

If yes, please describe

Please check any of the following MUSCULOSKELETAL conditions below that currently affect you or that you have experienced in the last 5 years.*

Please check any of the following RESPIRATORY conditions below that currently affect you or that you have experienced in the last 5 years.*

Please check any of the following CIRCULATORY conditions below that currently affect you or that you have experienced in the last 5 years.*

Please check any of the following DIGESTIVE conditions below that currently affect you or that you have experienced in the last 5 years.*

Please check any of the following SKIN conditions below that currently affect you or that you have experienced in the last 5 years.*

Please check any of the following NERVOUS SYSTEM conditions below that currently affect you or that you have experienced in the last 5 years.*

Please check any of the following OTHER conditions below that currently affect you or that you have experienced in the last 5 years.*

The above information is accurate and true to the best of my knowledge. I understand that massage therapists do not diagnose disease, prescribe medications, or manipulate bones. I further understand that massage therapy is not a substitute for medical attention or exam. I take responsibility for alerting my practitioner to any physical, mental or emotional changes that occur with my health.*