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Please take time to fill in the wellness registration form before you come in.

In order to protect & ensure the safety of the Client, the Massage Therapist must be aware of any existing conditions.
 
First Name:
M.I.
Last Name:
Address:
City:
State:
Zip:
Phone(h):
Phone(w):
Date of Birth:
Referred by:
Is this your first massage? Yes
No
I get them sometimes
I am a regular
Pleas list any medications, vitamins, or any pharmaceuticals being taken (include explanation for its use):
What is your reason for this visit?
Are you currently under a physcians care? Yes
No
Please select any of the following: Diabetes
Dislocation
Pain
Carpal Tunnel
TMJ Syndrome
Headaches
Varicose Veins
Fever
Cold
High Blood Pressure
Fibromyalgia
High Blood Pressure
Low Blood Pressure
Heart conditions
Please list any conditions not listed:
Are you pregnant? Yes
No
If yes, what trimester? Is this your first pregnancy?
 
 
Understand a Massage Therapist is not a substitute for a Physician, and does not diagnose conditions. Massage serves as a relaxation form of therapy, to reduce, relieve muscle tension, spasms, & increase circulation.

Feedback during and after session is appreciated & welcomed.
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