Gust Check In Form

Are you current pregnant ?

Yes No

If you are pregnant how far long and any high risk factors ?

Are you taking any medications?

Yes No

If Yes please list name and use below

Have you had any orthopedic injuries？

Yes No

If yes, please list:

Please indicate any of the following that apply to you

What pressure do you prefer for your massage?

Light Medium Deep

Consent

By signing below, you agree to the following. I have complete this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Please Sign your name below *

Clear