no yes have you recently had surgery (within last 3 years), if yes, please explain
no yes are you currently on any medications (include OTCs, NSAIDS, supplements)? if yes, please explain
no yes do you have any known allergies? if yes, please explain
no yes are you currently seeing a health care provider for any reason? if yes, please explain
no yes do you have any medical conditions the massage therapist should be aware of? if yes, please explain
no yes have you suffered a recent injury? if yes, please explain
no yes do you have a chronic (long term) injury or illness? if yes, please explain
no yes are you pregnant? if yes, approximate delivery date
no yes do you have any numbness, tingling, swelling, fever or infection? if yes, please explain
no yes do you have any current skin rashes or other skin problems? if yes, please explain
no yes do you wear contact lenses or dentures? if yes which or both?
no yes do you have varicose veins? if yes, please explain
no yes do you have arthritis? if yes, please explain
no yes do you have high or low blood pressure? if yes, please explain
no yes do you have any heart problems of which you are aware? if yes, please explain
no yes do you have frequent headaches? if yes, please explain
1 (low) 2 3 4 5 (medium) 6 7 8 9 10 (high) please rate your general tension level?
no yes do you have any other medical conditions of which I should be aware? if yes, please explain
what do you hope to accomplish through massage therapy