MEDICAL INFORMATION

Name*

First NameLast Name

E-mail*

Cellnumber*

Birthday*

MonthDayYear

Click all the applicable boxes: I..*

If you have high blood pressure, to you take tablets?

If you have high blood pressure, is it under control?

If applicable, list surgeries in the last two years

If applicable, list broken bones in last two years

If applicable, tension or soreness in which area?

if applicable, where is the numbness or stabbing pain?

If applicable, which area is sensitive to touch or pressure

Requirements from client / More information wanted?

I understand that the massage/bodywork I receive is provided for relaxation, stress reduction and the relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for a physical ailment I may be aware of.

I understand that massage therapists/body workers are not qualified to adjustments, diagnose, prescribe, or treat physical or mental illness and that nothing said in the course of the session(s) given, should be construed as such.