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 you *Vehicle AccidentWhiplashHeadachesHeart AttackStrokeHigh/Los Blood PressureDiabetes ScoliosisDisk ProblemsBroken BonesSprainsProsthetics/Artificial JointsArthritis/Joint AcheFibromyalgiaHepatitisHIVCancerBreast AugmentationEdemaSkin DisordersAbdominal PainDigestive DisordersSurgeryIf you have had past surgery, please provide us with more details 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