Name: _____________________________________________ 

Address: _________________________________________________

City: ___________ZIP____________Phone:_____________________

DOB:_________________

How did you hear about Simply Massage Therapy? __________________________________________

Yes  No

___ ___ Do you frequently suffer from stress?

___ ___ Do you experience frequent headaches?

___ ___ Are you pregnant?

___ ___ Are you diabetic?

___ ___ Do you have high blood pressure?

___ ___ Are you epileptic?

___ ___ Have you had any recent surgeries?

___ ___ Have you had any broken bones in the last two years?

___ ___ Do you have tension or soreness in a specific area?

___ ___ Do you have cardiac or circulatory problems?

___ ___ Do you suffer from back pain?

___ ___ Do you have numbness or stabbing pains?

___ ___ Are you sensitive to touch/pressure in any area?

___ ___ Do you have any other medical condition I should be aware of?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage work may be contraindicated. A referral from you primary care provider may be required prior to services being provided. I understand that the massage work I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage therapy should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session(s) given should be construed as such. Because massage therapy is contraindicated under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile, and understand that there shall be no liability on the practitioner's part should I forget to do so. It is also understood that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Appointments that are not cancelled or rescheduled within 24 hours will be billed to clients acct.

Sign: __________________________________ Date: __________________________