Name
Age
Gender
Female.
Male.
Your Address
E-mail address
If you want to be called, your phone number:
Referred by:
Have you been in a massage session before?
yes
no
If yes, how long ago?
General and Medical Information
Please answer every question and explain when necessary
Are you under any stress right now?
yes
no
Do you have Diabetes?
yes
no
Do you suffer from frequent Headaches?
yes
NO.
Do you have Arthrits?
yes
no
Are you Pregnant?
yes
no
Do you have High Blood Pressure?
yes
no
Are you under any medication right now?
yes
no
If yes, what medication and for what condition?
Do you suffer from Epilepsy?
yes
no
Do you suffer from swelling or inflamation of joints (articulations)?
yes
no.
Do you have Varicose Vains?
yes
no.
Have you been under surgery lately?
yes
no
Please explain:
Do you have any contagious disease?
yes
no
Please explain:
Do you have Osteoporosis?
yes
no
Do you suffer from Back Pain?
yes
no
Do you feel numbness or pain in any part of your body?
yes
no
Please explain:
Are you sensible to the touch or pressure in any part of your body?
yes
no
Please explain:
Do you get bruised easily (hematomas)?
yes
no
Do you suffer from allergies?
yes
no
Please explain if your allergies are nasal or skin :
Have you been in an accident, have a fracture or lesion in the last two years?
yes
no
Please explain :
Do you have tension or pain in any part of your body?
yes
no
Please explain :
Do you have circulation or heart problems?
yes
no
Please explain :
Do you have any medical condition that we should know about?
yes
no
Please explain :
I understand that the massage is for relaxation and relieve of muscle tension. If I feel pain or uncomfortable during the sesion I'll inform the masseuse so he/she can adjust the amount of pressure or manipulation to a level I can tolerate.
I understand that a massage can not substitute a medical exam, diagnosis or treatment and that I should seek professional treatment with a Quiropractor or Medical Specialist for any physical or mental problem that I should have.
I understand that the masseuse is not qualified to perform adjustments to the spine (vertebral column), diagnose , prescribe or treat any problem physical or mental that I should have and anything said during the session can not be interpreted as that.
I will keep the masseuse inform of any changes in my health or medical status and I will not make any complains against the masseuse.
I understand that because a massage may not be given under specific medical conditions I certify that everything I said about my health is the truth and I answer every question with honesty.
I understand that any comment, suggestion, approach or asking for sexual favors from me to the masseuse will be a disrespect and it will terminate the massage session immediately and the fee amount paid in full. I understand that this kind of behavior will not be tolerate under any circumstances.
Note: If you disagree to these terms and conditions or if you are not really interested in our services please don't send this form. Thanks for your time.
