Therapeutic Massage Questionnaire Step 1 of 4 25% Client InformationName* First Last Home PhoneMobile PhoneEmail Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleAre you pregnant?*YesNoOccupationEmergency Contact* First Last Emergency Contact Phone* General InformationIn order to plan a massage session that is safe and effective, please complete the information below. Please answer the questions to the best of your knowledge.Have you had a professional massage before?YesNoIf yes, how often do you receive massage therapy?Do you have any difficulty lying on your front, back or side?YesNoIf yes, please explain:Do you have any allergies to oils, lotions or ointments?YesNoIf yes, please explain:Do you have sensitive skin?YesNoAre you wearing? Contact Lenses Dentures Hearing Aid Please select all that apply.Do you sit for long hours at a workstation, computer or driving?YesNoIf yes, please describe:Do you perform any repetitive movement in your work, sports or hobby?YesNoIf yes, please describe:Do you experience stress in your work, family or other aspect of you life?YesNoIf yes, how do you think it has affected you health? Anxiety Insomnia Irritability Muscle Tension Please Select All That Apply Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?YesNoIf yes, please identify:Do you have any particular goals in mind for this massage session?YesNoIf yes, please explain: Medical HistoryIn order to plan a massage session that is safe and effective, please complete the information below.Are you currently under medical supervision?YesNoIf yes, please explain:Do you see a chiropractor?YesNoIf yes, how often?Are you currently taking any medication(s)?YesNoIf yes, please list:Please check any condition listed below that applies to you: Allergies/Sensitivity Artificial Joint Atherosclerosis Back/Neck Problems Cancer Carpal Tunnel Syndrome Circulatory Disorder Contagious Skin Condition Current Fever Decreased Sensation Deep Vein Thrombosis/ Blood Clots Diabetes Easy Bruising Epilepsy Fibromyalgia Headaches/Migraines Heart Condition High or Low Blood Pressure Joint Disorder Open Sores or Wounds Osteoarthritis Osteoporosis Phlebitis Recent Accident or Injury Recent Fracture Recent Surgery Rheumatoid Arthritis Sprains/Strains Swollen Glands Tendonitis Tennis Elbow TMJ Varicose Veins Please Select All That Apply Please explain any condition that you have marked above:Is there anything else about your healht history that you think would be useful for your massage therapist to know to plan a safe and effective massage session for you? Notices & Informed ConsentDraping will be using during the session- only the area being worked on will be uncovered. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18. I understand that the massage I receive is provide for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile and understand that there shall be no liability on the massage therapist’s part should I fail to do so. Acceptance of Notices & Informed Consent*I have read and accept the above terms.I do not accept the above terms.EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.