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Personal Information
Please take a moment to fill out the form.
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required
How did you hear about me?
Have you ever had a professional massage before?
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Yes
No
Emergency Contact
Emergency Contact
Relationship
Phone
Medical Information
Are you taking any medications?
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Yes
No
If yes, please list name and use:
Do you suffer from chronic pain?
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Yes
No
If yes, please explain (What makes it better? What makes it worse?)
Please indicate any of the following that apply to you.
*
Required
Cancer
Headaches/Migraines
Arthritis
Diabetes
Joint Replacement(s)
High/Low Blood Pressure
Neuropathy
Fibromyalgia
Stroke
Heart Attack
Kidney Dysfunction
Blood Clots
Numbness
Sprains or Strains
None/Other
Please explain any of the conditions marked above
Are there any areas (feet, face scalp, etc.) that you do not want massaged?
Are you currently pregnant?
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Yes
No
If yes, how far along and are there any high risk factors?
Have you had any orthopedic injuries?
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Yes
No
If yes, please list
What type of massage are you seeking?
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Relaxation
Therapeutic/ Deep Tissue
Other
If you selected other, please explain
What pressure do you prefer?
*
Required
Light
Medium
Deep
Do you have any sensitivites or allergies? If so, please explain
What are your goals for this treatment session?
Please specify any specific areas where you would like your massage focused.
By signing, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.
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