Please provide the name and phone number of your preferred emergency contact(s)
Check all that apply. Note medication(s) taken for EACH condition checked in "Medications, Supplements, Vitamins" section.
(not required) If you would like tell me more about any of the conditions you checked above please do so here. For example: acute, chronic, frequency, known triggers, etc.
List all that apply to ensure proper precautions are taken. If "none" please note.
List all known food and drug allergies (even if you don't think it applies to massage). If "none" please note.
Note any current surgeries, injuries, and accidents within the last year including approximate dates. If "none" please note.