Preferred Method of Contact (Please choose One)*
Emergency Contact Name, Relationship to Client & Phone*
Primary Physician, Clinic Name & Phone Number
How would you rate your overall health?
Have you ever received a professional massage?*
Reason for seeking massage therapy*
In order to better address your goals, please state your specific concerns and approximate date of onset*
What is your exercise level?*
Do you perform any repetitive movements in your work, hobbies, sports, ect.?*
Check all activities that apply to you*
Do you have stress in your work, family, or other aspects of your life?*
Have you had any recent accidents, injuries or surgeries (in the past 6 months)?*
Do you have any allergies/sensitivities to oils, lotions or scents? *
Please list any current medications (prescription and over the counter) or supplements you take and what they are treating. **LIST NONE, IF YOU DON'T TAKE ANYTHING.***
Do you have experience with Essential oils?
Any other medical conditions not listed above
Waiver of Liability and Consent to have Massage*
