What kind of pressure do you prefer? ___________________________________________________________________

List area(s) you’d like specific attention to: _____________________________________________________________

List area(s) to avoid: ______________________________________________________________________________________

List allergies and/or injuries: ____________________________________________________________________________

List goal(s) for this treatment: ___________________________________________________________________________

How would you like to feel after your treatment? ______________________________________________________

Modality or style of massage, if known: _________________________________________________________________

Check all that apply:

™ Operation in past 3 months Neuropathy

™ Acute injury in past 3 months High or low blood pressure

™ Current skin irritation Osteoporosis

™ Pregnancy recent or current Cancer

™ Varicose veins Epilepsy

™ Inflammation or arthritis Diabetes

™ Cardio-vascular condition(s) Pinched nerves

™ Edema Challenges with menses, conceiving, or menopause

Is there anything else you’d like your therapist to know? ______________________________________________

™I certify that I am in good health and able to receive massage therapy. *

™I have notified my therapist of all known medical conditions and injuries. *

™I will immediately express if I experience any pain or discomfort during the treatment. *

I release my therapist from any liability due to treatment(s) and/or products used. *

Signature:* _________________________________________________________________________________________________