Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Date of last massage *

MM

DD

YYYY

Areas of concern *

Neck

Shoulders

Upper back

Middle back

Lower back

Upper legs

Lower legs

Feet

Do you have/had any of the following conditions?

Bone or Joint Disease

Tendonitis/Bursitis

Arthritis/Gout

Jaw pain (TMJ)

Lupus

Spinal Problems

Heart Conditions

High Blood Pressure

Thrombosis/Embolism

Fibromyalgia

Headache

Tingling/Numbness

Pregnant

Allergies

Athletes Foot

Rashes

Cancer/Tumors

Diabetes

Chronic Fatigue

Chronic Pain

Sleep Disorders

Anxiety/Stress Syndrome

Depression

Contact Lenses

Pace Maker

Other conditions not listed

By clicking "Agree and Consent" I am stating that I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health. I understand that a massage therapist cannot diagnose illness, disease or any other medical, physical or emotional disorder nor perform any spinal manipulations. I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is therapeutic health aid and is non-sexual.

I understand that if I arrive late, my session will end at the originally scheduled time so the client following me is nor penalized.


It is my choice to receive massage therapy, and I give my consent to receive treatment. I have reported all health conditions that I am aware of and will inform my practitioner of any changes in my health. *

Agree and Consent

Date *

MM

DD

YYYY