YOUR STORY
Name
Phone
Format: (000) 000-0000.
Email
exemple@exemple.com
Occupation
Emergency Contact
What brings you in today?
What would make today's session feel successful?
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HEALTH & LIFESTYLE
Current medical conditions
Yes
No
Details if yes
Past surgeries and dates
Yes
No
Details if yes
Recent injuries or accidents
Yes
No
Details if yes
Prescription medications
Yes
No
Details if yes
Supplements and vitamins
Yes
No
Details if yes
Allergies or sensitivities
Yes
No
Details if yes
Areas of chronic tension or pain
Yes
No
Details if yes
Current medical conditions:
Past surgeries and dates:
Recent injuries or accidents:
Prescription medications:
Supplements and vitamins:
Allergies or sensitivities:
Areas of chronic tension or pain:
Lifestyle Snapshot
Sleep Quality (1-10):
Energy Level (1-10):
Stress Level (1-10):
Water Intake:
Exercise Routine:
Self-Care Practices:
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PREFERENCES, BODY MAP, CONSENT & SIGNATURE
Preferred Pressure: Light / Medium / Firm / Deep
Areas to Focus On
Areas to Avoid
Essential Oil Preferences
Prayer at the End of Session?
Yes
No
BODY MAP (CHECK ALL THAT APPLY)
Body Parts
Headaches/Migraines
Neck
Shoulders
Upper Back
Mid Back
Low Back
Hips
Glutes
Legs
Knees
Feet
Hands/Wrists
Additional Notes:
I understand massage therapy is for wellness and relaxation.
I understand massage therapy is not a substitute for medical care.
I have disclosed all known health conditions and medications.
I may stop or modify treatment at any time.
I consent to receive massage therapy services from Modern Massage.
Client Signature
Date
-
Mois
-
Jour
Année
2 digit month, 2 digit day, 4 digit year
Date
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