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Date of Birth Home Phone Work Phone Cell Phone Who may we thank for referring you? Are you under a physician's care? YesNo If yes,please explain: Are you taking any medications? YesNo If yes,list medications and/or conditions associated with medications: Do you have any allergies? If so, please list: Have you had any surgeries in the last month? YesNo If yes, please explain: Have you ever received a professional massage? YesNo Are you pregnant? YesNo Please check all those that apply: Muscle Tightness or SorenessTrouble SleepingRestless LegsInflammationAnxietyHeadachesStressRecent InjuryTensionAching LegsContagious DiseaseArthritis If there are other choices not listed that apply to you and need mentioning, list here: Is there a specific body area on which you would like the therapist to concentrate?: (example: shoulders, neck, low back, etc.) What results would you like to achieve? Have you receieved any other treatment for your condition? MedicationSurgeryPhysical TherapyChiropractic CareOther If there are other choices not listed that apply to you and need mentioning, list here: I understand that this is a professional massage/reflexology session and is in no way, sexual in nature. If the practitioner feels that any inappropriate gestures are made by the client, he/she reserves the right to end the session immediately, with payment due in full. I understand that Massage and Reflexology are compliments to healthcare and not a substitute for medical supervision of any condition. If I have any medical condition that requires a physician’s care, I have consulted him/her regarding receiving a Massage/Reflexology treatment, and either have their consent, or have taken responsibility for the session upon myself. I certify that the above information is correct to the best of my knowledge. I will not hold my massage therapist or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. I have disclosed all medical conditions that I am aware of and will inform my massage therapist of any changes in my health status.