User:Ldichter

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Name:

Phone:

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Occupation:

Date of birth:

Emergency contact...phone


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Service specific questions
Have you had a therapeutic massage before? Y N

How often do you receive massage?

Do you have any allergies? Y N list___

Skin sensitivities Y N

Are you wearing contacts, prosthetic, dentures, wig, hearing aid...

Can you lay on your back, stomach comfortably?

Are you experiencing stress...anxiety...insomnia…

Do you engage in any repetatiave motion in your work or hobbies?

Are you currently experiencing any pain...explain

What goals do you have for your session today?

Medical History
Back/Neck pain

Scoliosis

Vericose veins

Joint disorder

Arthritis (kind)

Osteo Perosis

Artificial Joint

Epilepsy

Cancer History

Diabetes

TMJ

Fibromialgia

Carpel Tunnel

Tennis Elbow

Pinched nerve

Contageous Skin Condition

Open wounds or sores

Recent Surgery

Recent Fracture

Muscular Sprains/Strains

Fever/Swollen Glands

Autoimmune disease

Allergies/Sensitivities

Heart Condition

High/Low Blood Pressure

Easy Bruising

Circulatory disorder

If Pregnant how many months?

Other medical condition your massage therapist should know.

Medical Questions
Are you currently under medical supervision? If so explain. Are you currently seeing a chiropractor? Y N Previous surgery Are you currently taking any medications… What other forms of self care are a part of your preventative health care routing...ie yoga, healthy eating, acupunture, exercies etc.