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