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.

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Health Questionnaire
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
Street Address*
City*
Zip/Postal Code*
Home Phone*
Business Phone
Occupation
Emergency Contact*
Physician
Primary reason for massage therapy*
Conditions that apply to you	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
Explanation of any areas listed
Explanation of any pain
Medications
Surgeries
By selecting this button I am agreeing that I have read the disclaimer below this form...*
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.

By Brenda Rowell Copyright © 2010-2023 Benefits-of-Massage-Therapy.com

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