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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First name

Email Address

Age

Last name

Date of Birth

Referred By

Health Information

Are you taking any medications *

No

Yes

If you answered yes to any question, please elaborate

Any allergies? (oils, lotions, nuts, fruits, etc) *

No

Yes

If you answered yes to any question, please elaborate

Are you pregnant? *

No

Yes

If yes, how many months and due date

Select which apply

Areas of swelling

Autoimmune disorder

Back / neck problems

Bleeding disorders

Blood clots

Bruised easily

Bursitis

Cancer

Contagious condition

Decreased Sensation

Diabetes

Fibromyalgya

Headaches

Heart condition

Select which apply

Hypertension

Kidney Disease

Multiplesclerosis

Neurological condition

Neuropathy

Osteoarthritis

Osteoporosis

Phlebitis

Sciatica

Seizures

Stroke

Tendinitis

TMJ disorder

Varicose veins

Vertigo / dizziness

Areas of broken skin (rash, wounds) *

No

Yes

If you answered yes to any question, please elaborate

Recent injuries or medical procdures in the past 2 years *

No

Yes

If you answered yes to any question, please elaborate

Recent injuries or medical procdures in the past 2 years *

No

Yes

If you answered yes to any question, please elaborate

Please describe any other injuries or health conditions

Massage Information

Have you had proffesional massage before? *

No

Yes

If so how recently?

Reason for seeking massage *

Relaxation

Specific problem

How much pressure do you prefer? *

Light

Medium

Firm

By signing below, I acknowledge that I am aware of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.

Your Signature

Thanks for submitting!

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