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Massage Client Health History Form

Please fill out the following form to help us customize your massage.

Have you recently suffered an acute injury?
Have you had any recent surgery?
Check the box if you have or have had recent prolems with any of the following:

Please take a moment to carefully read the following information and sign where indicated.

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 pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/ or strokes may be adjusted to my level of comfort.

I further understand that massage should not be considered as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment I am aware of.


I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session(s) given should be considered as such.


Because massage is contraindicated under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and understand that there shall not be liability on the practitioner's part should I forget to do so. 

Thank you for submitting!

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