Massage Questionnaire

Name *
Name
Birthday
Birthday
Address
Address
Phone
Phone
Emergency Contact
Name
Name
Phone
Phone
General Health Information
Current Health Concerns (please state your health concerns and check all that apply)
Severity
Frequency
Symptoms
Changes
Severity
Frequency
Symptoms
Changes
Treatment received, Medications, Activities limited by Condition and any additional comments
Please provide information for the past 5 years, including type, approximate dates and treatment of any: Surgeries, Major Illnesses or Injuries.
Health Conditions
(check any current and previous conditions
General
Skin Conditions
Muscles & Joints
Cardiovascular & Respiratory
Nervous System
Endocrine System
Digestion & Elimination
Reproductive System
Cancer or Tumors

Please read the following before submitting. Hitting submit means you understand and agree to the terms below.

I understand that I will be receiving therapeutic massage. I understand the purpose of massage therapy is to establish and maintain good health and physical condition. I understand that massage is not intended to treat medical conditions and should not be construed as a substitute for medical examination, diagnosis, or treatment and should not take the place of a doctor’s care. I understand that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I further understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

Because massage therapy should not be performed under certain circumstances, I affirm that I have stated all of my medical conditions and answered all questions honestly. I agree to keep my therapist updated if there are changes in any medical conditions or my health status, and I understand that there shall be no liability on the practitioner’s part should I fail to do so.

I understand that either the therapist or the client may request a change in treatment or behavior should either be experiencing discomfort inappropriate to the situation. I understand that payment is required at the end of the session unless previous arrangements have been made. I understand I will be charged if the session is cancelled without at least 24 hours notice.

Understanding all of this, I give my consent to receive care.