GREAT BRIDGE THERAPEUTIC MASSAGE
greatbridgemassage@gmail.com | 757.579.9111
Full Name
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Medical Information
Are you taking any medications? If so, please list name and use:
Are you currently pregnant? If so, please state how far along and any high risk factors:
Do you suffer from chronic pain? If so, please explain the nature of your pain, what makes it better, and what makes it worse:
Have you had any orthopedic injuries? If so, please list:
Please indicate any of the following that apply to you:
Arthritis
Blood Clots
Cancer
Diabetes
Fibromyalgia
Headaches/Migraines
Heart Attack
High/Low Blood Pressure
Joint Replacement(s)
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Explain any conditions indicated above:
Massage Information
Have you had a professional massage before?
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What type of massage are you seeking?
Relaxation
Therapeutic/Deep Tissue
Other
What pressure do you prefer?
Light
Medium
Deep
Do you have any allergies or sensitivities? If so, please explain:
What are your goals for this treatment session?
Please annotate any areas of discomfort on the image below:
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