Date

MM

DD

YYYY

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Have you received massage therapy or bodywork before *

Yes

No

Have you had alcohol within the last 24 hours? *

Yes

No

Any Allergies? (Oils, lotion, nuts, fruit, skin, etc.)

Yes

No

Are you pregnant? *

Yes

No

Are you taking medications? *

Yes

No

Do you exercise?

Yes

No

** Please mark any of the following conditions you may currently have:

Area of swelling

Autoimmune disorder

Back/neck problems

Bleeding disorders

Blood clots

Bruise easily

Bursitis

Cold or Flu virus

Fever within 24 hours

Open wounds

PMS

Diabetes

Fibromyalgia

Headaches

Heart condition

Hypertension

Kidney disease

Grief process

Sinus congestion

Sports injury

Emotional changes

Acute pain

Phlebitis

Chronic pain

Seizures

Varicose veins

Wear contact lenses

TMJ disorder

Infection

Vertigo/dizziness

Recent Surgery

Other, please specify

I hereby state that, to the best of my knowledge, all my answers are correct. I understand that my personal health information will be collected, and that all information that I provide will be kept confidential unless required by law. I understand massage is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist does not prescribe medical treatment nor perform spinal manipulations. I will inform the therapist of my current condition at the time of each visit.