Health Form | CC massage+bodywork

First name

Last name

Email

Phone

Birthday

Address

Occupation

Emergency Contact Name & Phone

Are you currently under a physicians care for an acute or chronic illness?

Yes

No

If yes please explain:

Are you currently taking any prescribed medication or dietary supplements?

Yes

No

If yes, please list:

Have you received a massage before?

Yes

No

How did you hear about me?

What are your goals for this session?

Please list areas of tension, stress and/or pain you wish to be addressed

HEALTH INFORMATION: Please select all current conditions and past conditions

Elaborate on noted areas above

Please list any recent injuries or surgeries within the past 5 years:

Please list your stress-reduction activities, hobbies, exercise and/or sport participation:

By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

Health History