Client Record: Massage

Please complete this form. This information is critical to your session(s) as it may affect the focus and outcome of it. All information disclosed will be kept for session purposes only and in strict confidentiality.

First Name

Last Name

Appointment Date

Treatment

Massage History/Information

Have you ever received Massage Therapy?

Yes

Date of last massage?

Are there any areas you DISLIKE to be massaged?

(Ex: face, scalp, feet, abdomen, buttocks)

Have you (ever) been diagnosed with Deep Vein Thrombosis or a history of blood clots? If so, please explain

Please mark the correct box for any conditions that you currently have or have had in the past:

Allergies

HIV/AIDS

Bone/Joint Disease

Jaw Pain/TMJ

Bone/Joint Injury

Lower Back/Hip Pain

Hepatitis A, B, or C

Muscle Spasms

Cancer

Numbness/Swelling

Depression

Pacemaker

Diabetes

Painful Feet/Swelling

Fibromyalgia

Pregnant

Headaches/Migraines

Stiffness

Head Injuries

Tendonitis

Heart Condition

Vertigo

High Blood Pressure

Warts

Botox or filler injections

If pregnant, how many weeks?

Please indicate the primary reason(s) for your visit today:

Relaxation

Pampering

Stress Relief

Therapeutic

Pain Management

Other

Other:

**If you experience any pain during the session(s), please immediately inform the therapist, so that the work can be adjusted to your level of comfort.

I confirm that, to the best of my knowledge, the answers above are correct, and I have not withheld any relevant information. I hereby agree to hold eména spa and its staff members harmless in the event I sustain any injury or damage to my person, directly or indirectly, as a result of receiving spa and beauty treatments. I agree to release eména spa and staff memebers from any claim; cause of action, suit, damages etc. that may result from any such injury or damage.

Signature

Date

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Client Record: Massage

Massage History/Information

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