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.
Date
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Referred by:
Date of birth:
/
Month
/
Day
Year
Date
Emergency Contact (name/phone):
Have you ever received a professional massage?
Yes
No
What are your reasons for receiving massage therapy today?
Onset of condition:
Cause (if known):
Has your condition been diagnosed by a Medical Doctor?
Yes
No
Would you be interested in receiving acupuncture and/or Chinese herbs for this condition?
Yes
No
Maybe
Conditions
Please check any condition(s) of which I should be aware:
Stress
Muscular pain
Carpal tunnel
Asthma
Anxiety
Low back pain
Athlete’s foot
Allergies
Tension headache
Neck pain
Digestive problems
Sinus trouble
Migraine
Arthritis
Crohn’s disease
High blood pressure
Insomnia
Osteoporosis
Constipation
Cancer
Fatigue
Tendonitis
Diarrhea
Diabetes
Depression
Sciatica
IBS
Varicose veins
PMS
Disc problems
Weight issues
Blood clots
Menopause
Plantar fasciitis
Respiratory
Pregnant
Muscle spasm
TMJ
AIDS/Hepatitis C
Other
Do you have any allergies to massage lotions, oils, or essential oils? If yes, please list:
Sleep
Do you sleep well?
All the time
Most of the time
Some of the time
Hardly ever
Do you fall asleep easily?
Yes
No
Sometimes
Do you wake during the night?
Yes
No
Sometimes
Do you fall back to sleep easily?
Yes
No
Sometimes
Do you have lots of dreams?
Yes
No
Sometimes
Do you have sleep apnea?
Yes
No
Do you get night sweats?
Yes
No
Sometimes
Do you feel rested when you wake?
Yes
No
Sometimes
Do you nap during the day?
Yes
No
Sometimes
Average hours of sleep per night:
Energy level from 1 to 10 (10 being best)?
Neuromuscular Pain
Where is the primary area of pain in your body?
Describe your pain:
Dull
Achy
Sharp
Cramping
Burning
Numbness
Fixed
Refers
Stiffness
Swelling
Moves around
Throbbing
Constant
Comes & goes
Worse AM
Worse PM
Worse in cold weather
Worse in hot weather
Other
Pain Scale from 1 to 10 (10 being the worst):
Does heat make it feel better?
Yes
No
Sometimes
Does cold make it feel better?
Yes
No
Sometimes
Have you received any physical therapy or other types of therapy for your pain?
Yes
No
Do you take any prescription medicine for your pain? If yes, please specify:
Stress
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?
Diet
How would you describe your diet?
Unhealthy
Fair
Good
Fantastic
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:
Exercise
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?
Additional comments:
Thank you for
filling out this form.
All information is kept confidential.
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