Massage Health form

Thank you for your interest in booking a massage with me, please fill in the following to the best of your knowledge. Once received,I will confirm your appointment time or adjust the time slightly.

- Step 1 of 2

Name *

Email *

Phone *

Location

Date of Birth:

Preferred Pronouns?

Height (ft)

(for massage table adjustments)

Occupation: *

to understand posture , activity

Did you want to come to the Studio, or me coming to you?

• Oakland Studio
• Mobile massage

Massage length *

• 60mn
• 90mn
• 2h
• Customized time (2+hrs)

How would you rate your General health

• Excellent
• Good
• Fair
• Poor

Vaccinated? (Covid19)

• First dose.
• NO
• FULLY (up to date)
• YES ( not the latest)

Have you had a professional massage before

• Yes
• No

when was this?

Great, What are your Goals in seeking massage therapy today? *

Goals and intention.

Now , what kind of Massage are you more interested in?

• Swedish
• Deep Tissue
• Vibrational Healing
• Myofascial
• All (integrative)

What kind of pressure do you prefer? *SoftMediumDeepVery Deep

Ok, now can you tell me which part of your body needs attention? (please describe) *

Next

List any excercise activities and frequencies:

Have you had surgery recently?

• No
• Yes

If yes:

Any Alergies?

Do you have/had any of the following?

• Bone or joints disease
• Spinal problems
• Rashes / infections
• Migraines / headaches
• Jaw Pain
• Tendonitis
• Athlete's foot
• Breathing difficulty
• High/Low blood pressure
• Lymphadema
• Diabetes
• Blood clots
• Cardiovascular problems
• Sciatica

describe

Any Injuries , illnesses, accidents still affecting you?

Any Input, Health concerns or something you would like to share ?

Preferred Essential oils:

• None / no scent please
• Lavender
• Mint
• Eucalyptus
• Jasmin
• Rose

Location

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

• I agree

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. If I experience any discomfort during this session, I will inform the practitioner so that the pressure may be adjusted to my level of comfort.

• I agree

I understand that a massage therapist can not diagnose illness, disease, or any medical disorder. I am responsible for consulting a physician or physical therapist for any physical ailments I have. I am aware of the benefits and risks and give my consent for massage. I_understand that massage therapy is a therapeutic health aide and is non-sexual. I_understand that all information that I provide will be kept confidential.

• I agree

Today's Date

Signature

Name

Submit