Opening : By Appointment Only
Address : 9009 Long Point Rd Suite A2 Houston, TX 77055
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Massage therapy Intake form
PERSONAL INFORMATION
Gender:
Male
Female
Non-Binary
MEDICAL INFORMATION
Do you have any of the following?
Yes
No
If yes, please check all that apply:
High Blood Pressure
Low Blood Pressure
Heart Disease
Arthritis
Diabetes
Blood Clots
Fibromyalgia
Neuropathy
Headaches / Migraines
Anemia
Asthma / Breathing Issues
Skin Conditions
Cancer
Epilepsy / Seizures
Thyroid Disorder
Liver / Kidney Disease
Stroke
Osteoporosis
Multiple Sclerosis
Pregnancy
Other:
Are you currently pregnant?
Yes
No
Do you have any allergies?
Yes
No
If yes, please list:
Are you taking any medications?
Yes
No
If yes, please list:
MASSAGE INFORMATION
Have you had a professional massage before?
Yes
No
What type of massage are you seeking today?
Relaxation
Deep Tissue
Therapeutic
Prenatal
Other:
What is the primary reason for your visit?
What areas would you like us to focus on?
Are there any areas you do NOT want massaged?
What pressure do you prefer?
Light
Medium
Deep
How would you like to start your session?
Face Up (on back)
Face Down (on stomach)
HEALTH HISTORY
Please check any conditions or symptoms you have had in the past 6 months:
Fever
Night Pain
Headaches
Dizziness
Numbness / Tingling
Loss of Sleep
Loss of Weight
Anxiety / Stress
Digestive Issues
Neck Pain
Shoulder Pain
Mid Back Pain
Low Back Pain
Hip / Groin Pain
Knee / Leg Pain
Joint Stiffness
Muscle Pain
Sciatica
TMJ / Jaw Pain
Carpal Tunnel
Arthritis
Sinus Issues
Skin Issues
Fatigue
Other
CONSENT TO TREATMENT
I understand that massage therapy is not a substitute for medical care. I have stated all my known medical conditions and will inform my therapist of any changes. I understand that massage therapy is based on the client's needs on the day of service and may include draping for modesty. I have read and understand the above and consent to treatment.
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