Skincare/Massage Consultation Form

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Massage Consultation Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
How did you hear about us?*

Website / Online SearchFacebookInstagramOtherAnother client referred me (tell us who so we can thank them please!)
If you were referred, please let us know who from
If Other, please let us know
Massage Goals
Have you ever had a massage before?*

YesNo
What is primary reason for massage today?*

RelaxationPainDecrease in range of motionInjuryOther
Have you seen a physician /chiropractor for your current concern?
Choose the option that best fits your goal:

Develop treatment plan/strategy to address my primary concernEnjoy relaxing massageOccasional or single visit for massage.Regular massage therapy to correct and maintain my massage goals
Do you use prescription medication to manage pain or inflammation? Please answer y/n and list medication if used
Your Health
Please indicate any medical conditions you are currently receiving treament for*

Cancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFrequent Cold SoresHIV/AIDSHeadaches / MigrainesThyroid diseaseHormone ImbalanceDental restorationsHepatitisOtherNot being treated for any medical conditions
Do you?*

Have a pacemakerHave metal implantsHave irregular heartbeatHave a seizure disorderHave cancer and am recieving treatments nowrecently had cancer but are currently not receiving treatmentsDo you have an insulin pump or monitoring patch?None of these apply to me
Please list your medications. (please include oral contraceptives or hormone replacement). If you take no medicine please reply none
Please list supplements you use. If you take no supplements please reply none.
Any known allergies?*

AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsNo known allergiesOther
If yes, please specify what and date last used
Are you a smoker? *

YesNoSocial
Do you drink half your body weight in ounces of water daily?*

YesNo
Type of exercise you do regularly (at least 1 time per week)

aerobic (HITT classes, orange theory)stretching/barre classesyogaTia Chi or QiGongmeditation/breathing
Please further describe your exercise or stress management routine. Please list any mobility issues in regards to range of motion or chronic pain here
Are you claustrophobic?*

YesNo
Please rate your stress level*

LowMediumHigh
Please indicate preferred massage pressure*

LightMediumHeavyDeep Tissue
FEMALE CLIENTS
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Any menopause symptoms?*

YesNoN/A
If yes, please specify
I have honestly and completely completed this form. I understand this information is confidential.

Yes
Please verify that you are human*
Signature*

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Date*

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Massage Consultation Form

Massage Goals

Your Health