New Client Form

Have you had a professional massage before?

Yes

No

Do you have any difficulty lying on your front, back, or side?

Yes

No

Do you have any allergies to oils, lotions, or ointments?

Yes

No

Do you have sensitive skin?

Yes

No

Are you wearing contact lenses? (optional)

dentures

a hearing aid

Do you sit for long hours at a workstation, computer, or driving?

Yes

No

Do you perform any repetitive movement in your work, sports, or hobby?

Yes

No

Do you experience stress in your work, family, or other aspect of your life?

Yes

No

If yes, how do you think it has affected your health?

muscle tension

anxiety

insomnia

irritability

other

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?

Yes

No

Do you have any particular goals in mind for this massage session?

Yes

No

Are you currently under medical supervision?

Yes

No

Do you see a chiropractor?

Yes

No

Are you currently taking any medication?

Yes

No