Name
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First Name
Last Name
DOB
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MM
DD
YYYY
Phone
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(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Occupation
How did you find me?
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Emergency Contact (Name, Relationship, Phone)
Are you currently taking any medications?
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If yes, please list name and use:
Do you have computer implants such as a pacemaker, insulin pump or spinal stimulator?
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Are you currently pregnant?
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Do you suffer from chronic pain?
If yes, please explain:
Have you had any recent injuries or surgeries?
If so, please explain what type of injury/surgical procedure and it's cause/reason.
Please indicate any of the following that apply to you:
How would you describe your general health?
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It isn't the best. I struggle often.
It is okay, but not as good as it could be.
I try to maintain good health.
I consider myself healthy.
How would you describe your lifestyle?
Consider: Dietary Habits, Exercise Habits, Rest, Stress Levels, Emotional well being, Work-Life Balance, Overall Happiness + Satisfaction.
Do you take in high amounts of any of the following?
Have you had a professional massage before?
What type of pressure do you prefer?
Do you have any allergies or sensitivities?
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If yes, please explain:
What are your goals for this treatment session?
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Ob/Gyn/Midwife handling your care
At the time of my massage appointment, I am:
How many weeks Pregnant or Postpartum are you at the time of your appointment?
What is your estimated due date or when was baby's birth date?
Types of births you have had in the past
Did you have any complications or medical issues with this pregnancy?
If yes, please explain in more detail:
Check any of the following that you have experienced during this pregnancy or postpartum:
Other:
If applicable, when do you plan to return to your former occupation?
Is there anything else you want your therapist to know?
The body undergoes a lot of change during pregnancy and immediately following. Feel free to use this space to share anything else that has been on your mind or heart.
Do you now, or have you recently had any respiratory or flu symptoms?
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Have you had a fever in the last 24 hours?
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Have you been in contact with anyone in the last 14 days who has had COVID-19 symptoms?
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Would you prefer your practitioner to wear a mask during your appointment?
Cancellation Policy Acknowledgement
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I acknowledge this business's 24-hour cancellation policy stating that should I cancel within 24 hours of my reserved appointment time, or that if I do not show up, I am still responsible for paying for 100% of the service I had scheduled.
