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Health Information

Consent for Treatment

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 any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners 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/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. 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. Understanding all of this, I give my consent to receive care.

Date: October 23, 2025

First Participant's Name
First Name*
Last Name*
Phone*
Select Gender
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Third Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Fourth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Fifth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Sixth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Seventh Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Eighth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Ninth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Tenth Participant's Name
First Name*
Last Name*
Select Gender
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Select Gender
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Contact Information:
Do you have a physician referral/prescription? *
No
Yes
Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?*
No
Yes
Physician/Health-care Provider name:
Practitioner/Clinic Name:
Referred by:
Phone:

Massage Information

Have you ever received professional massage/bodywork before?*
No
Yes
How recently?
What types of massage/bodywork do you prefer?
What kind of pressure do you prefer? *
Light
Medium
Firm
What are your goals/expected outcomes for receiving massage/bodywork?
List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):
Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?*
No
Yes
Explain:
List the medications you currently take:
Are you wearing contacts?*
No
Yes
Are you wearing dentures? *
No
Yes
Are you wearing a hairpiece?*
No
Yes
Are you pregnant? *
No
Yes

Health History

Have you had any injuries or surgeries in the past that may influence today’s treatment?
Check any of the following health conditions that you currently have (If you are unsure, please ask): *
blood clots
infections
congestive heart failure
contagious diseases
pitted edema
None

Please answer honestly, as massage may not be indicated for the above conditions.

Please indicate conditions that you have or have had in the past. Explain in detail, including treatment received:

Current or Past - Muscle or joint pain:
Current or Past - Muscle or joint stiffness:
Current or Past - Numbness or tingling:
Current or Past - Swelling:
Current or Past - Bruise easily:
Current or Past - Sensitive to touch/pressure:
Current or Past - High/Low blood pressure:
Current or Past - Stroke, heart attack:
Current or Past - Varicose veins:
Current or Past - Shortness of breath, asthma:
Current or Past - Cancer:
Current or Past - Epilepsy, seizures:
Current or Past - Headaches, Migraines:
Current or Past - Neurological (e.g. MS, Parkinson’s, chronic pain):
Current or Past - Dizziness, ringing in the ears:
Current or Past - Digestive conditions (e.g. Crohn’s, IBS):
Current or Past - Gas, bloating, constipation:
Current or Past - Kidney disease, infection:
Current or Past - Arthritis (rheumatoid, osteoarthritis):
Current or Past - Osteoporosis, degenerative spine/disk:
Current or Past - Scoliosis:
Current or Past - Broken bones:
Current or Past - Allergies:
Current or Past - Diabetes:
Current or Past - Endocrine/thyroid conditions:
Current or Past - Depression, anxiety:
Current or Past - Memory Loss, confusion, easily overwhelmed:
Comments:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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