Client General Information Form Page 3
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4Kneaded Relief Day Spa
Client Massage Form
Name_____________________________________
Have you had a professional massage before?
Yes □
No □
Do you have any difficulty lying on your □ front, □ back or □ side?
If yes, please explain: _____________________________________
Do you sit for long hours at a workstation, computer, or driving?
Yes □
No □
Do you perform any repetitive movement in your work, sports, or hobby? Yes □
No □
Do you see a chiropractor?
Yes □
No □
If yes, how often? ________________
Please identify any tight, tense, or sore areas or areas of chronic muscular pain that you would like the
therapist to address. You may also mark them on the figures below:
Muscles/Joints
Circle one: Pain/Stiffness/Spasms
Current
Previous
Neck
______
______
Low Back
______
______
Mid Back
______
______
Upper Back
______
______
Shoulders
______
______
Left/Right Leg
______
______
Left/Right Knee
______
______
Please explain ___________________
_______________________________
Please check any of the following conditions that may pertain to you.
The information you give will help us determine the most safe and effective treatment for you.
(
)
(
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Insomnia
Smoker ___Past ___Present
(
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(
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Chronic Fatigue
Sinus
(
)
(
)
Depression/Anxiety
Chronic Cough
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)
(
)
Difficult Digestion/Constipation
Frequent Colds
(
)
(
)
Bruise Easily
Shortness of Breath/Asthma
(
)
(
)
Skin Conditions:
Other Breathing Problems
Type:__________________
Type:_________________
(
)
(
)
Earaches
Spinal Problems
(
)
Type:_____________
Jaw Pain/TMJ
(
)
(
)
Multiple Sclerosis
Osteoporosis
(
)
Sciatica
(
)
Foot Problems
(
)
Paralysis
___Athletes Foot
(
)
Seizures
___Warts
(
)
Parkinson’s Disease
___Bunions
(
)
Prosthesis
(
)
Menstrual Problems/PMS
___Pins
(
)
Menopausal Problems?
___Limbs
(
)
Breast Tenderness
If necessary, please explain any condition that you have marked above:__________________________
____________________________________________________________________________________
____________________________________________________________________________________
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