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Call To Book: (302) 500-1013
Massage Health History
We cannot accommodate guests in their first trimester for massage or any body work
.
Your Information
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Email
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Emergency Contact Name
Emergency Contact Phone
Relationship
Occupation
Referred By
Health History
Anxiety / stress
Yes
No
Bleeding disorder
Yes
No
Blood clot
Yes
No
Bursitis
Yes
No
Bruise easily
Yes
No
Cancer / tumor
Yes
No
Depression
Yes
No
Diabetes
Yes
No
Fibromyalgia
Yes
No
Hearing loss
Yes
No
High blood pressure
Yes
No
Low blood pressure
Yes
No
Kidney disease
Yes
No
Multiple sclerosis
Yes
No
Muscle weakness
Yes
No
Neuropathy
Yes
No
Osteoarthritis
Yes
No
Osteoporosis
Yes
No
Phlebitis/varicose veins
Yes
No
Rheumatoid arthritis
Yes
No
Sciatica
Yes
No
Seizures
Yes
No
Stroke / CVA
Yes
No
Tuberculosis
Yes
No
Tendinitis
Yes
No
TMJ disorder
Yes
No
Vertigo / dizziness
Yes
No
Vision impairment
Yes
No
Skin conditions
Yes
No
Neurological conditions
Yes
No
Heart condition
Yes
No
Autoimmune disorder
Yes
No
Digestive problem
Yes
No
Endocrine disorder
Yes
No
Respiratory disorder
Yes
No
Areas of swelling
Yes
No
Frequent headaches
Yes
No
Areas of numbness or decreased sensation
Yes
No
Areas of numbness or decreased sensation
Yes
No
Areas of broken skin
Yes
No
Where?
Any current infectious or contagious conditions?
Yes
No
Please list
Are you taking any medications?
Yes
No
Please list
Any allergies or hypersensitivities?
Yes
No
Please list
Are you pregnant?
Yes
No
Due Date
MM slash DD slash YYYY
History of joint replacement surgery?
Yes
No
Please list
Any implants? (e.g. pacemaker, insulin pump, metal)
Yes
No
Please list
Are you you currently under medical supervision or receiving other medical interventions?
Yes
No
Please describe
Recent injuries or medical procedures in the past 2 years?
Yes
No
Please describe
Please describe any other injuries or health conditions:
Have you had professional massage before?
Yes
No
How recently?
Reason for seeking massage:
Relaxation
Other
How much pressure do you prefer?
Light
Medium
Firm
Please list any areas of pain or discomfort
We cannot accommodate guests in their first trimester for massage or any body work.
(Required)
I understand and am not in my first trimester of pregnancy.
Consent
(Required)
I agree.
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 accurately and truthfully to the best of my knowledge. I also agree to inform my massage therapist of any health or medical changes.
