Bodyscapes Massage Therapy Form
Please complete this form (10 minutes) and click "Submit". This form must be submitted no less than 24 hours prior to your appointment time . If you need to save the form and finish completing it later, press the "Save" button at the end of this form. A pop-up box will appear to get your email address. The form will be emailed to you to complete when it is convenient for you.
Street Address Line 2
State / Province
Postal / Zip Code
Date of birth:
Emergency Contact (name/phone):
Have you ever received a professional massage?
What are your reasons for receiving massage therapy today?
Onset of condition:
Cause (if known):
Has your condition been diagnosed by a Medical Doctor?
Would you be interested in receiving acupuncture and/or Chinese herbs for this condition?
Please check any condition(s) of which I should be aware:
Low back pain
High blood pressure
Do you have any allergies to massage lotions, oils, or essential oils? If yes, please list:
Do you sleep well?
All the time
Most of the time
Some of the time
Do you fall asleep easily?
Do you wake during the night?
Do you fall back to sleep easily?
Do you have lots of dreams?
Do you have sleep apnea?
Do you get night sweats?
Do you feel rested when you wake?
Do you nap during the day?
Average hours of sleep per night:
Energy level from 1 to 10 (10 being best)?
Where is the primary area of pain in your body?
Describe your pain:
Comes & goes
Worse in cold weather
Worse in hot weather
Pain Scale from 1 to 10 (10 being the worst):
Does heat make it feel better?
Does cold make it feel better?
Have you received any physical therapy or other types of therapy for your pain?
Do you take any prescription medicine for your pain? If yes, please specify:
How would you rate your current stress level?
Acute (occurs for short periods of time causing anger, irritability, anxiety, periods of depression, headache, pain, stomach upset, dizziness, heart palpitations, shortness of breath, hypertension and bowel disorders)
Chronic (brought on by long-term exposure to stressors that cause more serious and chronic health issues such as chronic fatigue, clinical depression, sleep disorders, high blood pressure, auto-immune disorders, etc.)
Episodic (will last longer than acute stress causing periods of intermittent depression, anxiety disorders, emotional distress, ceaseless worrying, and persistent physical symptoms similar to those found in acute stress. symptoms often associated with Type A personality)
Mild (symptoms are mild and dissipate quickly. No long term effects)
Do you receive weekly counseling/psychotherapy?
Do you regularly do any awareness practices (meditation, yoga, tai chi, prayer, affirmations, etc?
What are the primary causes of stress in your life?
How would you describe your diet?
How is your appetite?
How many meals do you eat daily?
How much water do you drink daily?
Do you drink caffeine? How many ounces daily?
Are you a vegetarian or vegan? List your sources of protein:
List any food allergies or sensitivities:
Do you eat regularly at fast food restaurants?
Times per week you eat out?
Do you eat a lot of processed foods?
Do you think you get enough fresh fruits, vegetables, and whole grains daily?
Do you smoke cigarettes? How many per day:
How often do you exercise?
What kind of exercise do you do?
Do you like to exercise?
Are there any reasons and/or conditions that prevent you from exercising regularly? Please specify:
How would you describe your health in general?
Thank you for
filling out this form.
All information is kept confidential.
Should be Empty: