*Emergency Contact Phone Number:
*Have you had a professional massage or facial before?Select:YesNo
If yes, how often?
*Do you have any difficulty lying on your front, back, or side?Select:YesNo
If yes, please explain?
*Do you have any allergies to oils, lotions, or ointments?Select:YesNo
In order to plan a massage and facial session that is safe and effective, we need some general information about your medical history.
*Are you currently taking any medication?Select:YesNo
If yes, please list medications.
*Have you been tested for COVID-19? NoYes
If yes, what type of test did you have? When was your test? What were the results?
Have you been in places with a high infection rate within the last two weeks (e.g., state designated “hotspots”)? If yes, please explain.
Please check if you are experiencing any of the following as a NEW PATTERN since the beginning of the pandemic: FeverChillsCoughSore throatDiarrhea, digestive upsetNasal, sinus congestionLoss of sense of taste or smellFatigueShortness of breathSudden onset of muscle soreness (not related to a specific activity)Rash or skin lesions (especially on the feet)
Do you have any new discomfort with exertion or exercise?
Please check any condition listed below that applies to you: diabetesback/neck problemsvaricose veinsosteoporosisepilepsyheadaches/migrainesheart conditionhigh/low blood pressuredeep vein thrombosis/blood clotsjoint disorder/rheumatoidarthritis osteoarthritis/tendonitiscancerFibromyalgiaTMJcarpal tunnel syndromecontagious skin conditionopen sores or woundseasy bruisingrecent accident or injuryrecent fracturerecent surgerysprains/strainscurrent feverswollen glands
Are you pregnant? If so, how many months?
Please explain any condition that you have marked above:
Is there anything else about your health history that you think would be useful for your practitioner to know to plan a safe and effective massage session for you?
Draping will be used during the session - only the area being worked on will be uncovered. I understand that the massage I receive is provided 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. I declare that the information provided above is true and accurate to the best of my knowledge.
*Digital Signature of Client
Digital Signature of Parent / Guardian (if applicable)