Massage Therapy Questionnaire Template printable pdf download

Massage Therapy Questionnaire

Name:__________________________________________

Date of Initial Visit:_______________

Address: __________________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________________

Phone: (Day) ____________ (Evening) ____________(Cell) ____________(Email)_______________________________

Date of Birth: ____________________________________

Occupation: _____________________________________

Employer: __________________________________

Referred By: _____________________________________

Physician: __________________________________

1) Have you ever had Massage Therapy before?

Yes_____ No_____

2) Do you have difficulty lying on your front, back, or side?

Yes______ No______

3) Do you have allergic reactions to oils, lotions, ointments, liniments, or other substances put on your skin?

Yes_____ No____ If yes, please explain____________________________________________

4) Do you wear contact lenses ( ), dentures ( ), a hearing aid ( )?

5) Do you experience stress in your work, family, or other aspects of your life? Yes____ No____

-How would you describe your stress level? Low___ Medium ___ High ____ Very High ____

-If high, how do you think your stress has affected your health? Muscle Tension ( ),

-Anxiety ( ), Insomnia ( ), Irritability ( ), Other _____________________________________________________

6) For women: Are you pregnant? Yes ___ No ___ If yes, how many months? ______

7) What is your major complaint, if any that you want to improve? ____________________________________________

__________________________________________________________________________________________________

8) When did you first notice this complaint? ______________________________________________________________

9) What event(s) brought it on? ________________________________________________________________________

__________________________________________________________________________________________________

10) What activities aggravate the condition? _______________________________________________________________

11) What have you done to get relief? ____________________________________________________________________

12) What are your expectations for this visit?

________________________________________________________________

13) Are you currently under medical supervision? Yes ____ No ____

14) Are you currently taking any medications? Yes ___ No ___ If yes, please list: ________________________________

___________________________________________________________________________________________________

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Massage Therapy Questionnaire Template