Fields marked with an * are required HTML PERSONAL INFORMATION First Name * Last Name * Phone * Email * Address City Zip Occupation How do you prefer to be contacted? * Email Phone Call Text Message Divider HTML Copy GENERAL AND MEDICAL INFORMATION 1 - Have you ever had a professional Massage? YES NO If Yes, how often? 2 - Are you pregnant? YES NO If Yes, how far along? 3 - Do you have any medical conditions? If so, please list: 4 - Are you currently taking any medications? If yes, please list: 5 - Are you allergic or sensitive to anything? (e.g. essential oils, scents, etc.)? YES NO If Yes, please list below. 6 - Have you had any recent surgeries? YES NO If Yes, type of surgery and date 7 - Have you had any recent injures? YES NO If Yes, please list below. 8 - Do you sit for long hours at a workstation, computer, and/or driving? YES NO If Yes, please list below. 9 - Do you perform any repetitive movement in your work, sports, and/or hobbies? YES NO If Yes, please list below. 10 - Do you have any particular goal in mind for your massage (s)? YES NO If Yes, please list below. 11 - Is there a particular area of the body where you are experiencing tension, stiffness, pain and/or discomfort? YES NO If yes, use the diagram to list the area(s) below. HTML Divider If you are a human seeing this field, please leave it empty.
