Client Questionnaire

Welcome to the Retreat. Please take a few minutes to fill in the following information prior to your spa treatment. This will help us provide you with the best possible spa experience. We hope you enjoy your massage and that it enhanced your weekend of renewal. Thank you for your participation and enjoy!

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone *

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Occupation*

What is the primary reason for your appointment?*

The following questions will provide us with important information about your
current physical condition. Please answer as thoroughly as possible

Any recent injuries or surgeries?*

YesNo

Explain recent injuries or surgeries.

Do you have any back, neck or spinal problems?*

YesNo

Explain back, neck or spinal problems.

Do you have arthritis?*

YesNo

Where do you have arthritis?

Do you have any heart or blood pressure problems?*

YesNo

Explain your heart or blood pressure problems

Do you have varicose veins or blood clots?*

YesNo

Do you frequently suffer from stress?*

YesNo

Where do you suffer from stress?

Do you have any skin problems or allergies?*

YesNo

Explain your skin problems or allergies

Do you bruise easily?*

YesNo

Explain your bruising.

Do you wear contacts?*

YesNo

Are your contacts in now??

YesNo

Are you pregnant?*

YesNo

Have you ever had a professional massage?*

YesNo

Do you have any other medical condition? (ie: diabetes, ...)*

YesNo

Explain your other medical conditions.

Are you currently taking any medication?*

YesNo

Explain your medications.

GPSW Pain Diagram

Draw on Image

Informed Consent

I understand that massage given here is for the purpose of stress reduction, relief from muscular tension or spasm or for increase circulation and energy flow. If I experience any pain or discomfort during this session, I will immediately inform the massage therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

I further understand that the massage therapist does not diagnose an illness or disease. As such, the massage therapist does not prescribe medical treatments or medications, in addition, does not perform spinal manipulations.
It has been made clear to me that massage therapy is not a substitute for medical exam and/or diagnosis and it is recommended that I see a physician for any physical ailment I might have. Because the massage therapist must be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on my physical health.

I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session; and I will be liable for payment of the scheduled appointment.

Green Pastures Still Waters LLC