Massage for Health and Foot Spa LLC
759 Southwest Federal Highway #317 Stuart Florida 34994
Adrianna McConnell MA54837 MM35668
Please fill out the form below
Massage Therapist name:
Type of massage given to Client
Name:
Address:
Phone number:
Email:
Date:
Health information:
Are you taking any medications?
Do you have any allergies? (oils, lotions, nuts, fruits)
Are you currently under medical supervision or receiving other medical interventions?
If yes, please describe:
Please check yes or no to the following questions:
yes no Areas of swelling
yes no Autoimmune disorder
yes no Back/neck problems
yes no bleeding disorders
yes no blood clots
yes no Bruise easily
yes no Bursitis
yes no Cancer
yes no Contagious condition
yes no Decreased sensation
yes no Osteoporosis
yes no Phlebitis
yes no Sciatica
yes no Seizures
yes no Stroke
yes no Tendinitis
yes no TMJ disorder
yes no Varicose veins
yes no Vertigo/dizziness
yes no Areas of broken skin
If yes, where?
yes no Joint replacement surgery?
If yes, which joint?
yes no Medical procedures or injuries in the past 2 years?
If yes, please describe
Any other health conditions?
if yes, please describe
yes no Diabetes
yes no Fibromyalgia
yes no Headaches
yes no Heart conditions
yes no Hypertension
yes no Kidney disease
yes no Multiple sclerosis
yes no Neurological condition
yes no Neuropathy
yes no Osteoarthritis
Please circle any areas of discomfort
Have you had a professional massage before?
if yes, how recently?
How much pressure do you prefer?
Light
Medium
Firm
By signing below, I acknowledge that I am away of the benefits and risks of massage therapy and that I have completed this form to the best of my knowledge. I also agree to inform my massage therapist of any health of medical changes.
Client Signature:
Date:
Location
759 SW Federal Hwy 317
34994 Stuart
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