Massage Consultation Form

The following information will be used to help plan a safe and effective treatment. Please answer the questions to the best of your knowledge.

All information will remain private & confidential.

Name*

First NameLast Name

Gender*

FemaleMale

Date of birth*

Date

Occupation*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

example@example.com

Emergency Contact Name & Mobile

Name / Phone Number

How did you hear about me?*

Please mark any of the following conditions if you may currently have.*

If you have YES to any of the above or Other, please provide further information:

Have you had any surgery/operations recently?*

YesNo

If yes, please give details:

Have you had a sports injury, fracture or muscle strain recently?*

YesNo

If yes, please give details:

Do you know that you have any spinal problems?*

YesNo

If yes, please give details: (e.g scoliosis, kyphosis, lordosis, flat back, hernia, spine wear, chronic pain)

Do you have any hip problems?*

YesNo

If yes, please give details: (e.g arthrosis, prosthetics, deformity)

Are you allergic to anything? (e.g oils, creams, clothes)

If Yes, please details

What is your stress level now?*

LowAverageSomewhat StressedVery Stressed

How is your physical condion?*

Strong/FitNormalWeek

Do you do sport or improve your physical condition with any movement?*

Yes, RegularlyYes, Just sometimeNot at all

If Yes, what do you like to do?

What is you daily water intake?*

How many liters/day?

Did you get already any massage treatment?*

YesNo

If Yes, what types of massages have you tried and like?

Have you had any bad massage experience?*

YesNo

If Yes, what was wrong?

Are there any body areas that require special attention?

What level of pressure do you prefer during the massage?*

LightMediumStrongReally strong

How sensitive is your skin?*

SensitiveNormalNot Sensitive

What is your goal for this session?*

Are there any other information you would like to share with your therapist aware of with the treatment? If yes, please give details:

Booking and cancellation conditions for all current and future dates:
1/ If the booking is canceled less than 24 hours before the scheduled time, 50% of the handling fee will be charged.
2/ If the booking is canceled less than 2 hours before the scheduled time, or if the guest does not show up on time, 100% of the handling fee is payable.

CLIENT CONSENT and DECLARATION:
Please read the following statement and accept it:

1/ I, the undersigned client, hereby consent to receive "Fix Me Please" Massage & Mobility Services from Tamás Pali, Massage Therapist.
2/ I declare and I understand that it is my responsibility that I have provide accurate and truthful information about my health condition and any concerns
or about issues that may affect the massage treatment.
3/ I acknowledge that the massage may involve physical touch and joints manipulation of soft tissues for the purposes of
relaxation, stress relief, and alleviation of muscle tension, as well as to promote general well-being.
4/ I understand that it is my responsibility to communicate with the massage therapist during the treatment about any
discomfort, technique or changes in my condition.
5/ I acknowledge that massage services do not replace medical treatment, and I absolved Tamás Pali, Massage Therapist,
from any liability related to the massage therapy treatment or any potential side effects.
6/ I understand and acknowledge that I’m obliged to immediately inform the therapist of any changes in my health condition that may affect the massage treatment or its consequences.
7/ I understand that my therapist may require me to obtain permission from my doctor before my appointment.

We cannot take responsibility for problems caused by hidden diseases!

Signature*

Date*

Date

Massage Consultation Form

Your General Health Condition

Your Massage Experience