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Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
Please indicate which apply:
What type of massage are you seeking:
Preferred Pressure

Massage therapy is for the purpose of stress relief, relief from muscular tension and may offer temporary relief from pain and/or may be helpful in relieving insomnia. The massage therapist cannot diagnose any physical or mental illness. Massage is not a substitute for medical examination, diagnosis or treatment. It is you responsibility to see a a doctor for appropriate diagnosis or treatment of any physical or mental ailment you may have.

Thank you for completing your form

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