Zobeautiful BEAUTY Massage Consultation Form

Massage Consultation Form

Confidential & Secure
Name*

First NameLast Name
Daytime Phone Number*
Please enter a valid phone number.
Evening Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Employer
Primary Physician*
Emergency Contact
Relationship*
Emergency Contact Phone Number*

Area CodePhone Number
How did you hear about us?
Medical Information
Are you taking any medications?*

YesNo
Please list Medications and their use*
Are you currently pregnant?*

YesNo
If yes how far along?*
Any high risk factors?*
Do you suffer from chronic pain?*

YesNo
If yes please explain*
What makes it better?*
What makes it worse?*
Have you had any orthopedic injuries?*

YesNo
If yes, please list:*
Please Indicate any of the following that apply to you.*

CancerHeadaches/MigrainesArthiritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFybromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or StrainsVaricose VeinsUndiagnosed Lumps/BumpsOther
Please explain any conditions you have marked above:*
Massage Information
Have you had a professional massage before?*

YesNo
What type of massage are you seeking?*

RelaxationTherapeutic/Deep TissueOther
If Other please provide more information:*
What pressure do you prefer?*

LightMediumDeep
Do you have any allergies or sensitivities?*

YesNo
Please provide details regarding any allergies/Sensitivities you may have:*
Are there any areas (feet, face, abdomen, etc) you do not want massaged?*

YesNo
Please explain:*
What are your goals for this treatment session?*
Please mark any areas of discomfort - Draw on Image Right, Front, Back, Left
By signing below, you agree to the following.

I have completed 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.
Date*

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Date
Client Signature*

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Therapist Signature*

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Massage Consultation Form

Medical Information

Massage Information