Please check all conditions that apply now, past conditions, family history conditions.
All information obtained on this form will be kept strictly confidential. Certain medical conditions may be contraindicated for massage or may need a physician’s referral prior to receiving massage.
I understand that the massage I receive is provided for the purpose of basic relaxation and relief of muscle tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure/strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for a medical examination, diagnosis or treatment and that I should see a qualified medical specialist for any ailment. I acknowledge that massage should not be performed under certain medical conditions and 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 I understand that there shall be no liability on the practitioner’s part should I forget to do so. I state that I have consumed no intoxicating substance or non-prescribed drug prior to arriving for bodywork.