Zobeautiful BEAUTY Massage Consultation Form

Massage Consultation Form

Confidential & Secure
Name

First NameLast Name
Daytime Phone Number
Please enter a valid phone number.Format: 00000000000.
Evening Phone Number
Please enter a valid phone number.Format: 00000000000.
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?
Please list Medications and their use
Are you currently pregnant?
If yes how far along?
Any high risk factors?
Do you suffer from chronic pain?
If yes please explain
What makes it better?
What makes it worse?
Have you had any orthopedic injuries?
If yes, please list:
Please Indicate any of the following that apply to you.

Other
Please explain any conditions you have marked above:
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
If Other please provide more information:
What pressure do you prefer?
Do you have any allergies or sensitivities?
Please provide details regarding any allergies/Sensitivities you may have:
Are there any areas (feet, face, abdomen, etc) you do not want massaged?
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

DayMonthYear
Date
Client Signature
Therapist Signature
Should be Empty:

Massage Consultation Form

Medical Information

Massage Information