Profile for Massage Today’s Date……………......
Name………………………………………………. Date of Birth……………………………………….
Address………………………………………………………………………………………………………
Phone…………………………………….. Email………………………………………………………….
How did you hear about Massage Sway?......
What prompted you to come in today?
……. Relaxation ……. Injury/pain ……. Other……………………..
……. Stress ……. Personal growth
Are you currently afflicted by any of these conditions?
…… Arthritis ……. Osteoporosis ……. Sore Throat
…… Varicose Veins ……. Heart Ailments ……. Blood Clots
…… Edema ……. Carpal Tunnel ……. Phlebitis
…… Diabetes ……. Sports Injury ……. Allergies
…… High Blood Pressure ……. Neck/Spine Injury ……. Bruise easily
…… Pregnant ……. Recent Surgery ……. Other………………………
If PREGNANT, how many weeks along are you?
…………………………………………………………………………………………………………………
If PREGNANT, have you experienced any complications, past or current?
……………………………………………………………………………………………………………......
Have you undergone surgery? If yes, please explain.
………………………………………………………………………………………………………………….
Are you currently under the care of a health professional for injuries/medical treatment?
If yes, please explain.
…………………………………………………………………………………………………………………...
Please list any medications you are currently taking
……………………………………………………………………………………………………………………
Additional Questions
Are you under the age of 17? ...... Yes …... No
If yes, you must have written consent of a parent or guardian to receive a massage.
Have you ever received massage therapy before? ……. Yes ….... No
Do you smoke? …….Yes ……. No If yes, how often………………………………………………
How much water do you drink per day? ……………………………………………………………….
Any additional heath condition your therapist should be aware of? …….No …….Yes
If yes, please explain…………………………………………………………………………………………
Gender preference for your future appointments ……Male …….Female …….No Preference
Areas of pain/tension/discomfort………………………………………………………………………….
Areas to be avoided………………………………………………………………………………………….
Preferred type of touch ……..Light/Meditative…….Heavy/Invigorating…….Deep/Trigger Point
Please read the following information and sign below:
1. I understand that massage therapy is not a substitute for medical examination, diagnosis, or treatment and is provided for the purpose of relaxation and relief of muscular tension. If at any time during the session I experience pain or discomfort I will inform the therapist.
2. Being that massage should not be done under certain medical conditions, I affirm that I have answered all above questions pertaining to medical conditions truthfully.
3. This is a therapeutic massage and any sexual remark or advances will terminate the session and will be liable for payment of the scheduled treatment.
4. The therapist will not perform breast massage on females.
5. Appropriate draping will be used at all times during the massage session.
6. If uncomfortable for any reason the client or therapist may ask to end the massage session, and the session will be ended.
Guest Signature……………………………………………………..Date……………………………………
Therapist Name……………………………………………………..Date…………………………………….