Massage Health Form

Name *

Phone *

Location

Date of Birth:

Preferred Pronouns?

Height (ft)

(for massage table adjustments)

Occupation:

to understand posture , activity

How would you rate your General health

Excellent
Good
Fair
Poor

Vaccinated? (Covid19)

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

when was your last massage?

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

Goals and intention.

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)

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

What kind of pressure do you prefer? *

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

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?

describe

Any Injuries , illnesses, accidents still affecting you?

Anything else you would like to share ?

Preferred Essential oils:

Location

Address Line 1

City

State

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

Signature

manixs