Massage Health Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Birth Date *Have you ever had massage therapy before? *YesNoDo you have allergic reactions to oils, lotions, ointments, liniments or other substances put on your skin? *YesNoWhat is your major complaint for today’s visit?Are you currently under medical supervision? *YesNo Are you currently pregnant? *YesNoIf yes, when is your due date?Have you been sick (cold, flu, fever, etc) in the last 7 days? *YesNoAre you taking medication? *YesNoIf yes, please list your medicationsAre you wearing/have any of the following?ContactsDenturesPace MakerPortsHearing AidsWhat are your goals for today’s massage?Please check off all below that apply to youVehicle AccidentWhiplashHeadachesHeart AttackStrokeHigh/Los Blood PressureDiabetesScoliosisDisk ProblemsBroken BonesSprainsProsthetics/Artificial JointsArthritis/Joint AcheFibromyalgiaHepatitisHIVCancerBreast AugmentationEdemaSkin DisordersAbdominal PainDigestive DisordersSurgeryIf you have had past surgery, please provide us with more detailsWould you like to enhance your mobile massage experience by adding an Aromatherapy Essential Oil?YesNoIf your answer to the above was yes, please select an essential oil option below:Anti-Stress / RelaxationEnergizingBalancingInvigorating I understand that massage is not in replacement for medical care and that no diagnosis will be made *I understandI have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on changes in my physical health. With this in mind, I agree that the massage therapist cannot be held liable for any problems that might arise as a result of my massage sessions. *I agreeGuardian Consent (if applicable)I consent to my child receiving massage servicesName of Minor (if applicable)Full Name (Digital Signature) *Date Signed *Submit
