Name:

Address:

City:

State:

Zip:

Telephone:

Occupation:

Employer:

Medication:

Physician:

Age:

Birth Date:

Referred By:

Primary Reason for Appointment:

Please answer the following questions by checking the appropriate answer. Please explain any Yes answers below.

1. Have you had a professional massage before?

2. Have you ever had surgery?

3. Do you have any spinal problems?

4. Are you pregnant? Do you have an IUD?

5. Do you wear contact lenses or dentures?

6. Do you take any prescribed medications?

7. Do you have chronic back pain?

8. Do you have frequent headaches?

9. Are you constantly tired?

10. Do you have any heart problems?

11. Do you  have high blood pressure?

12. Do you have varicose veins?

13. Do you have any blood clots?

14. Have you ever had cancer?

15. Do you have arthritis?

16. Have you ever suffered from an acute injury?

17. Do you have pain that radiates down your arms or legs?

18. Do you suffer from tension?

19. Do you have chronic diarrhea?

20. Do you have constipation?

Please explain any Yes answers:

Do you have any other medical condition which I should be aware?
If so please specify:

I, , understand that the massage therapy given here is for the purpose of stress reduction, relief from muscular tension or spasm, or for increasing circulation. 

I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder.  As such the massage therapist prescribes neither medical treatment or pharmaceuticals, nor performs any spinal manipulations.  It has been made very clear to me that this massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.

Because a 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.

Name:  Date: