Massage Consultation Form

Massage Consultation Form
Personal Information
Name
Phone
Address
Date of Birth
Email
example@example.com
Emergency Contact
How did you hear about AD Massage Therapy?
Medical Information
Are you currently taking any medication?

YesNo
If yes, please name and use.
Are you currently pregnant?

YesNo
If yes, how far along?
Any high risk factors?
Have you had any orthopaedic injuries? If yes, please list.
Do you suffer from chronic pain? If yes, what makes it better and what makes it worse?
Is there any medical information/history you feel I should be aware of? If yes, please explain.
Massage Information
Have you had professional massage before?

YesNo
What type of massage are you seeking?

Relaxation TheraputicDeep Tissue
What pressure do you prefer?

LightMediumFirm
Do you have any allergies or sensitivities? If yes, please explain.
Are there any areas you do not want massaged? If yes, please list.
What are your goals for this treatment session?
Are there any areas of discomfort? If yes, please list.
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.
Client Signature

Clear
Date

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