Massage Form

Referred? Yes No
By Whom?







Zip Code:


Home Phone:

Work Phone:



Are you currently under the care of a health professional? Yes No

If yes, health care provider's name: 

Provider's phone: 

Reason for your visit:

Do you have a history of or are currently treating any of the following conditions:

 emotional challenges  fever  insomnia
 headaches  allergies  obesity
 cancer  chronic pain  surgery
 elevated cholesterol  sports injury  thrombophlebitis
 phlebitis  cold virus  cigarettes
 heart ailment  ulcerated colon  circulatory problems
 diabetes  osteoporosis  digestive disorders
 infectious conditions  neck/spine injury  diverticulitis
 accidental injury  appendicitis  ulcers
 high blood pressure  athritis  whiplash
 acute pain  back pain

 medications (type/purpose)

 TMJ syndrome  constipation
 flu  epilepsy
 kidney ailment  heart problems  pregnancy
due date:
 varicose veins

Recent injuries or medical treatments:

Do you have any skin problems or allergies?

Are you taking any supplements or herbal treatments? Describe:

Sports you are engaged in:

Current workout program:

I understand that the massage therapy given here is for the purpose of stress and pain reduction, relief from muscular tension or spasm, and for increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals, or perform spinal manipulation. I understand that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see an appropriate health care provider for any physical ailment that I might have.

With this in mind, I agree to receive massage therapy and hold the therapist blameless for any problems that might arise as a result of the massage session

Yes, I agree     No, I do not agree