Healing With Heart Specialty Massage Therapy

Personal Information

Name

Phone

Email address

Address

City/State/Zip

DOB

Emergency Contact Name

Relationship

Emergency Contact Phone

How did you hear about us?

Medical Information

Are you taking any medications?

Yes No

List medications here:

Are you pregnant?

Yes No

How far along are you?

Any high risk factors?

Any chronic pain?

Yes No

Please explain here:

What makes it worse?

What makes it better?

Do you currently have any injuries?

Yes No

Please Explain:

Massage Information

Have you had a professional massage before?

Yes No

What type of massage are you seeking?

Relaxation Therapeutic/Pain Relief

Other?

What pressure do you prefer?

Light Medium Deep

Do you have any allergies or sensitivities?

Yes No

Please Explain:

Are there any areas you don't want massaged?

Yes No

Please describe any areas of discomfort or tenderness:

Please explain any injuries, surgeries or chronic pain/ health conditions you are experiencing or have experienced in the past:

Consent

By typing your name here, you are indicating that you have completed this form to the best of your ability, and agree to inform your therapist if any of the above information changes:

Date

Healing With Heart Specialty Massage Therapy

Personal Information

Medical Information

Massage Information

Consent

Kristen Steele

LMT