Please fill out the health history form below as soon as you can prior to your massage therapy appointment. It will allow me to prepare better for your specific needs and to attend to those needs more effectively during your massage session.

Health Questionnaire

Please note that all fields followed by an asterisk must be filled in.
Headaches, migraines
Sinus problems
Jaw Pain, TMJ dysfunction
Asthma, lung conditions
Digestive problems
Joint pain
Muscle, bone injuries
Numbness, tingling
Sprains, strains
Arthritis
Fibromyalgia
Cancer, tumors
Spine disorders
Diabetes
Pregnancy
Heart, circulatory problems
Stress, tension
Depression
Sleep problems
Allergies
Rashes, athletes foot
Infectious disease
Blood clots
Varicose veins
High/low blood pressure
Epilepsy/Seizures
Osteoporosis
Yes, I have read the disclaimer and agree.
I have read the disclaimer and do not agree

Please enter the word that you see below.

  

Please acknowledge that you have read the following statement by selecting the button above.

I understand that Bodywork I receive is provided for relief of muscular tension and medical/injury bodywork. If I experience any pain or discomfort during this session, I will immediately inform the Therapist so that the pressure of massage may be adjusted to my level of comfort. Bodywork should not be construed as a substitute for medical treatment and that I should see a physician, chiropractor, or other qualified specialist for any physical ailment of which I am aware.

I understand that Massage Therapists are not qualified to perform spinal 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. 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 Therapist updated as to any changes and understand that there shall be no liability on the therapist's part should I fail to do so.

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By Brenda Rowell Copyright © 2010-2016 Benefits-of-Massage-Therapy.com

Hippocrates said, "The way to health is to have an aromatic bath and a scented massage every day."



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