Healthform

Please complete this form to the best of your knowledge. Your information is kept private

Health Form - New Client

First Name

Last Name

Date of Birth

Pronouns

They/Them

She/Her

He/Him

Other

Occupation:

Height (ft)

How would you rate your General health?

Excellent

Good

Fair

Poor

List any excercise activities and frequencies:

when was your last massage?

What are your Goals in seeking massage therapy today?

which parts of your body needs attention? (please describe)

What kind of pressure do you prefer?

Massage length

60mn

90mn

120mn

150mn

Do you have/had any of the following?

Bone/joints disease

Sciatica

Cardiovascular problems

Spinal problems

Blood clots

Rashes/infections

Tendonitis

Migraines/headaches

Jaw Pain

Lymphadema

High/Low blood pressure

Diabetes

Breathing difficulty

Athlete's foot

Cat Allergy

Oil Allergy

Recent Surgery?

Injuries , illnesses, or accidents still affecting you?

Anything else you would like to share ?

Essential oils?

None / no scent please

Lavender

Mint

Eucalyptus

Jasmin

Rose

Prefered Location

3527 Grand Ave

Mobile Massage

East Oakland Studio ( close to the zoo)

Accessibility: Studio is not wheelchair accessible, there are stairs (20) to access the studio.

I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

I understand that the massage I receive is provided for the basic purpose of relaxation, stress reduction and relief of muscular tension. If I experience any discomfort during this session, I will inform the practitioner so that the pressure may be adjusted to my level of comfort.

I understand that a massage therapist can not diagnose illness, disease, or any medical disorder. I am responsible for consulting a physician or physical therapist for any physical ailments I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual. I understand that all information that I provide will be kept confidential.

I Agree