Do you have a history of or are currently treating any of the following conditions:

emtional challenges	fever	isomnia
headaches	allergies	obesity
cancer	chronic pain	surgery
elevated cholesterol	sports injury	thrombophlebitis
phlebitis	cold virus	cigarettes
heart ailment	ulcerated colon	circulatory problems
diabetes	osteoporosis	digestive disorders
infectious conditions	neck/spine injury	diverticulitis
accidental injury	appendicitis	ulcers
high blood pressure	athritis	whiplash
acute pain	back pain	medications (type/purpose)
TMJ syndrome	constipation
flu	epilepsy
kidney ailment	heart problems	pregnancy due date:
varicose veins

Recent injuries or medical treatments:


Do you have any skin problems or allergies?


Are you taking any supplements or herbal treatments? Describe:


Sports you are engaged in:


Current workout program:


I understand that the massage therapy given here is for the purpose of stress and pain reduction, relief from muscular tension or spasm, and for increasing circulation and energy flow. I understand that the massage therapist does not diagnose illness, disease, or any other physical or mental disorder. The massage therapist does not prescribe medical treatment or pharmaceuticals, or perform spinal manipulation. I understand that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see an appropriate health care provider for any physical ailment that I might have.

With this in mind, I agree to receive massage therapy and hold the therapist blameless for any problems that might arise as a result of the massage session

Yes, I agree     No, I do not agree