Massage Health Form - Good Viibes

Name AND pronouns *

Phone number

Email *

Date of Birth:

Height (ft)

(for massage table adjustments)

Occupation:

posture , activity

How would you rate your General health

Excellent
Good
Fair
Poor

List any excercise activities and frequencies:

when was your last massage?

What are your Goals in seeking massage therapy today? *

Goals and intentions

which parts of your body needs attention? (please describe) *

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

What kind of pressure do you prefer? *

Do you have/had any of the following?

Have you had surgery recently?

No
Yes

If yes:

Any Injuries , illnesses, accidents still affecting you?

Anything else you would like to share ?

Mobile Massage Request

Massage length *

60mn
90mn
120mn
150mn

Essential oils?

accessibility:

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 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 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 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

Signature

Massage Health & Consent Form

manixs