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Personal Info Form

Please disclose as much as information possible to help me provide you with the best massage :)

First name

Last name

Address

Occupation

Date of Birth

Phone

Recreational/Physical Activities:

State of Health/Wellbeing:

Are you currently seeing a health practitioner?

If you are on any medications, please state which kind:

Main Reason for Visit

Stress

Pain Relief

Relaxation

Other

Location of Problem or Pain:

Massage Preferences

Is there any part of your body that you do not want massaged?

Have you had any massage therapy before?

Medical Conditions

Please state if you currently have or have previously had any of the following conditions:

Inflammation

Infections

Spinal Problems

Diabetes

Skin Condition

Cancers

Sprains, Bruises, Varicose Veins

Fractures

Arthritis

Undiagnosed Pain

High/Low Blood Pressure

Are you pregnant?

Please provide additional details to marked yes:

Declaration

"I declare that all the above information is true. I have stated all of my known medical conditions and will keep the Massage Therapist updated on my health status during any treatments."

Date

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