RelaxCT- Customized Massage Session Form:
Please answer the following questions to the best of your ability, this information is strictly to assure you receive the best possible massage, customized for you.
Full Name
*
First Name
Last Name
How did you hear about RelaxCT?
How often do you receive professional massage?
Never Before
It’s been a while.
Once a year
Every six months
Every few months
Monthly or less
What pressure do you want used mostly in your massage session?
Light
Medium
Firm
Deep
Do you give permission to use hot stones or hot towels?
Yes
No
What areas of your body do you want AVOIDED in your massage session
Feet
Face
Scalp and hair
Glutes/hips
Abdomen
Pecs (women's breasts always avoided)
What areas do you want MORE FOCUS during your massage session?
Back
Neck and Shoulders
Legs
Hips/glutes
Feet
Scalp
Face
Hands
Are there special circumstances of your health that you need other directives for your massage therapist to plan out your massage session? If yes, please explain.
Rate your pain this week from 1 as the least pain and 5 as the worst pain.
Least Pain
1
2
3
4
Worst Pain
5
1 is Least Pain, 5 is Worst Pain
Rate your stress this week with 1 being the least stressed and 5 being the most stressed.
Least Stressed
1
2
3
4
Most Stressed
5
1 is Least Stressed, 5 is Most Stressed
RelaxCT and Chris Barbieri strive to create a safe enviorment for both parties. At any time during the apointment either party holds the right to stop the services and end the session for any reason. No reason needs to be given.
I understand and agree
Signature
Submit
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