This overview will give me the highlights of your needs. We can fill in the details when you come for your appointment. Please cut and paste this form and your answers into an email.

Health History Questions

Name:                                                                          Preferred phone number:

Address:                                                                       Birthdate:

Referred by:

Aprox. date last massasge:

Goals for massage session /  Body areas that need extra attention:

Areas to be careful:

Acute conditions:

Chronic conditions:

Major surgeries:

Motor vehicle accidents or other traumas or injuries:

Other health concerns:

Medications:

Frequent recreational activities / hobbies:

Filed under: