Questionnaire Health Questionnaire for Massage Therapy Name(required) Birth Date (YYYY-MM-DD)(required) Phone Email(required) Have you ever had a massage therapy before? Yes No Are you currently under medical supervision? Yes No Do you have allergic reactions to oils, lotions, ointments, liniments or other substances put on yourskin? What is your major complaint for today’s visit? Are you currently pregnant? (If yes, provide due date) Have you been sick (cold, flu, fever, etc) in the last 7 days? Yes No Are you taking medication? If yes, please list below. Yes No Medications Are you wearing/have any of the following? Contacts Dentures Pace Maker Ports Hearing Aids Do you currently have or have a history of the following? Accident Whiplash Headaches Heart attack Heart problems Stroke High/Low Blood Pressure Diabetes Edema Skin disorders Breast augmentation Hepatitis Abdominal pain Digestive Disorders Scoliosis Disc Problems Broken Bones Sprains Prosthetics Artificial Joints Arthritis/Joint Ache Fibromyalgia HIV Cancer I understand that massage is not in replacement for medical care and that no diagnosis will be made. I have stated all my known medical conditions and take it upon myself to keep the massage therapist updated on changes in my physical health. With this in mind, I agree that the massage therapist cannot be held liable for any problems that might arise as a result of my massage sessions. Signature (Type your name) Date (YYYY-MM-DD) Send
