Massage Form

Aug 2, 2022Aug 2, 2022

For most people physical activity and massage should not pose any problem or hazard. This consultation form is designed to determine if there are any hazards or contraindications before any massage intervention is implemented. Please answer the following questions as honestly as possible and use the space to give more information for those for which you have marked ‘YES’.

Name *

First

Last

ID Number

Age

Gender

Male
Female
Does it matter?

Preferred Contact Number

Cell-Work-Home

Email *

Emergency Contact Name *

Emergency Contact Number *

Doctor Name

First

Last

Doctor Contact Number

Has a doctor ever said that you have a heart condition and that you should only do exercise under their supervision?

Yes
No

Do you ever feel pain in your chest when doing exercise?

Yes
No

Do you ever suffer from dizziness?

Yes
No

Do you have any problems with your bones or joints?

Yes
No
Not Sure

Do you suffer from arthritis?

Yes
No
Not Sure

Are you currently on any medication?

Yes
No

List The Medication

List The Medications You are Currently Taking

Do you know of any reason why massage may be harmful?

Yes
No
Not Sure

Are you currently pregnant?

Yes
No
Not Sure

If Yes , which Trimester

Do you have a hernia?

Yes
No

Do you have diabetes?

Yes
No
Not Sure

Have you had any surgery within the last year?

Yes
No

List the surgeries you have had in the last year

Do You Have Any Of The Following(Please tick )

Heart disease
Blood vessel disorder/ disease
High Blood Pressure
High Cholesterol
Inflammatory conditions
Skin conditions
Neurological disorders
Back pain
Joint, tendon or muscular pain
Lung disease

Give a brief discription if you have any of the above

How do your muscles feel now?

Is there anything you would like me to focus on?

Do you experience any tightness or pain during performance?

How well do you hydrate during and after performance?

Anything else you would like to discuss that has not been indicated on this form?