Massage Pre-Treatment Questionnaire

Complete the form before your visit to help us tailor your treatment for a safe, relaxing experience.

Have you received a massage before?
Health Information
Are you currently under a physician’s care for an acute or chronic illness?
Are you currently taking any prescribed medication or dietary supplements?
Do you have any allergies?
Please check all current or past conditions
Do you have any difficulty lying on your front, back, or side?

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner.

I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension, spasm or pain and to increase circulation. If I experience any pain or discomfort, I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level. I understand that my massage therapist does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. I understand that I am receiving massage therapy at my own risk. By signing this release, I hereby waive and release the massage therapist, their principals, and agents from all claims and liability whatsoever from any and all liability, past, present, and future relating to massage therapy and bodywork.