Massage & Bodywork Questionnaire
Please fill in the form below.
Full Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Date Picker Icon
When was your last professional massage?
-
Month
-
Day
Year
Date
Date Picker Icon
What massage pressure do you prefer?
Light
Medium
Firm
Deep
How would you rate your level of stress?
1
2
3
4
5
Low
High
1 is Low, 5 is High
How often do you workout weekly?
0
1-2
3-4
5 or more
Please specify type (cardio, weight lifting, sport, etc.)
Do you have difficulty sleeping?
Yes
No
Occasionally
How many hours of sleep do you get on an average night?
Less than 4
4-6
6-8
More than 8
How many glasses of water do you drink daily?
1-2
3-5
6-9
10 or more
How often do you get headaches?
Rarely
1 or more times weekly
Frequently
I have chronic headaches
Do you sit for long periods of time during an average day?
I get up and walk at least once during the hour.
1-2 hour
3-4 hours
5 or more hours
Do you stretch?
Yes, daily.
Yes, before or after working out.
Yes, if I feel tight.
No.
Where are your problem areas? (Stiff, sore, limited range of motion, etc.)
Upper back, neck and shoulders.
Lower back, hips, glutes.
Legs and feet.
I am NOT comfortable receiving massage and bodywork on the following areas:
Glutes
Pecs
Feet
Scalp
Face
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. I am aware that it is my responsibility to inform the massage therapist of my current medical or health conditions and to update this history as needed. The treatments I receive here are voluntary and I release this institution and/or professional from liability and assume full responsibility thereof.
*
I have read and understand the conditions.
If I experience pain or discomfort during the session, I will immediately inform the massage therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold the massage therapist responsible for any pain or discomfort I experience during or after the session.
*
I have read and understand the conditions.
I understand that massage is entirely therapeutic and non-sexual in nature. Absolutely no explicit behavior or comments will be tolerated. The professional reserves the right to end service immediately and without refund if inappropriate actions take place.
*
I have read and understand the conditions.
Submit Form
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm