Massage / Body Treatment Form

First Name

Last Name

Date

Address

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City

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Zip Code

Daytime Phone

Cell Phone

Birth date

Male/Female

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Female

Please list any allergies you have.

Please list any medications you are currently taking including vitamins and dietary supplements.

Please list any surgeries you have had.

Please list any hospitalizations that you have had.

Have you ever had any massage work done before?

Why did you come for a massage today?

Are you or could you be pregnant?

Are You Presently under a doctor's care?

Do you smoke?

Do you exercise?

Some medical conditions could be contraindicated for massage. Please check if you have, had, or are currently experincing any of the following conditions:

I do hereby fully and willingly allow the massage therapist to give me a Massage. I have checked any medical conditions that apply, consulted with my doctor regarding such conditions and release the massage therapist/practitioner from all liability presently and in the future. I understand that this massage is strictly non-sexual and any inappropriate behavior will result in immediate termination of the session by either party.

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