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Health Questionnaire

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Preferred Pronouns *

Email *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Occupation?

How did you hear about Compassionate Massage? *

After your massage, may we contact you regarding your experience? *

Yes

No Thank You

Are you taking any mediations? *

Yes

No

If yes, what medications are you currently taking?

Please list any allergies you may have. *

(e.g. lotions, nuts, fruits, skin, etc.)

Are you pregnant? *

If you are pregnant, how many months along are you and when is your due date? *

Are you currently under medical supervision or other medical interventions? *

If yes, please describe.

Do you have any areas of broken skin? *

(i.e. wounds, rashes etc.)

If yes, where?

Do you have a history of joint replacement surgery? If so, where?

Do any of the following conditions apply to you? *

None of these

Areas of swelling

Autoimmune disorder

Back / neck problems

Bleeding disorders

Blood clots

Bruise easily

Bursitis

Cancer

Contagious condition

Decreased sensation

Diabetes

Fibromyalgia

Headaches

Heart condition

Hypertension

Kidney disease

Multiple sclerosis

Neurological condition

Neuropathy

Osteoarthritis

Osteoporosis

Phlebitis

Sciatica

Seizures

Stroke

Tendinitis

TMJ disorder

Varicose veins

Vertigo / dizziness

Recent injuries or medical procedures in the past 2 years? *

If yes, please describe

Please describe any other injuries or health conditions: *

Have you had a professional massage before? *

If so, how recently?

Reason for seeking a massage? *

How much pressure do you prefer? *

Please list and describe any areas of discomfort you may have: *

By submitting this form, I acknowledge that I am aware 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 or medical changes. *

Thank you!

(413) 522-8877

72 Center St, Northampton, MA 01060

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