Confidential Health Questionnaire
Mr, Mrs, Ms, Miss

Name _________________________________________________________________________________

Address _________________________________________________________________________________

City ______________________State __________ Zip ________________ Phone # _____________________

Date of Birth _____________________ M_____ F _____ Marital Status ___________

Employer ____________________ Occupation ______________________ Work # _____________

Phone # _______________ Cell# ________________ Can receive text message YES NO

Email __________________________________________________________

In Case of Emergency contact _________________________________________________________________
(Name) (Relationship) (Phone)
Are you currently under a doctor's care? Yes _______ No _________

If so, please explain ____________________________________________________________________
Are you on any type of medication? Yes _________ No ____________

If so, please list ________________________________________________________________________
Physician _____________________________________________________________________________
Chiropractor __________________________________________________________________________
Who may we thank for referring you ? _______________________________________________________
(Name) (Address)
Have you ever had massage therapy before ? Yes _________ No ____________
What results would you like to achieve from massage therapy ? ____________________________________
Are you Claustrophobic (fear of confined places) YES _____ NO ______
Do you like conversation during your massage ? YES _______ NO ________ SOME _________

PLEASE CHECK BESIDE ANY OF THE FOLLOWING YOU HAVE HAD IN THE PAST OR NOW HAVE.

_________ High Blood Pressure ___________ Bruise Easily
_________ Fibromyalgia ___________ Varicose Veins
_________ Circulatory Problems ___________ Osteoporosis
_________ Edema (swelling) ___________ Diabetes
_________ Epilepsy (seizures) ___________ Hepatitis
_________ Chronic Fatigue ___________ HIV
_________ Cancer ___________ Headaches

PLEASE TAKE A MOMENT TO CAREFULLY READ THE FOLLOWING & SIGN BELOW

I have completed the above form to the best of my Knowledge. I understand that massage therapy is for the purpose
of relaxation and relief from muscular tension and stress. The massage therapist dose not diagnose illness, perform
skeletal adjustments, or prescribe pharmaceuticals. I have stated all of my Known medical conditions and agree to keep
the practitioner updated to any changes in my medical profile. Any illicit or sexually suggestive remarks or advances
made by me will result in immediate termination of the session, and I will be liable for payment. I understand that
regardless of any claims filed on my behalf I am ultimately responsible for payment of services rendered.
I, also understand that cancelled or missed appointments without 24 hour notice may be charged 75% of the regular price
of the missed session. I give my Consent for massage.


Signature __________________________________________________________ Date ______________