Massage Form Name First Name Last Name Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Current medications * Sports & Activities * Allergies * Physician Name * Are you currently under medical care for any of the following? Check all that apply * Heart conditions Varicose veins Neck Injury Osteoporosis Diabetes Crohn's disease Nervous disorders high/low blood pressure phlebitis/circulatory problems back injury rheumatoid arthritis kidney disease asthma, respiratory inflammatory disease whiplash fainting or dizziness headaches or migraines jaw or ear pain osteoarthritis skin conditions fibromyalgia epilepsy none Other: Have you received a professional massage? * Yes No If yes, how often? Are you sensitive to touch/pressure in any area? * Yes No If yes, where? Have you had any surgery? * Yes No If yes, where? Have you had fractures/sprains in the past? * Yes No If yes, where? Have you had any serious illnesses in the past? * Yes No If yes, what? Are you pregnant? * Eve requires a doctor's written permission if you are in the first trimester. Yes No If yes, how far along? What relieves your pain? * What aggravates your pain? * How did your symptoms begin and when? * What level of pressure do you prefer? * Light Medium Firm Any other information your massage therapist should know How did you hear about us? Facebook/ Instagram Google Friend/ Family Thank you!
