Massage Consultation Form - Niagara Waters Spa
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2Niagara Waters Spa
Massage Consultation Form
Client Name:
Phone Number:
Address:
Cell Number:
Male
q Female
Please indicate:
q
Do you have known allergies?
Y N
If yes, what are they?
Are you presently taking any medications?
Y N
If yes, please specify:
When was your last complete physical examination?
General Health History
The massage you are about to receive is not considered a therapeutic massage. Swedish relaxation massage is only intended to relax
muscle tissue. We do not try to diagnose a medical condition, prescribe medical treatments, or treat specific conditions. The following
questions pertaining to your overall state of health are nonetheless necessary as any manipulation of body tissue will have some
consequences and in certain circumstances even the slightest manipulation is considered inadvisable.
It is recommended that all clients who receive a massage drink at least 8 glasses of water afterwards to help flush out
any toxins that have been released within the body as well to not engage in strenuous activities. If at any time this
massage becomes inadvisable it will be discontinued.
The following is a list of contraindications to receiving a body massage which will make this massage appointment
inadvisable or may results in certain body areas not being massaged. Please indicate if any are applicable to you. Your
Practitioner will review with you.
Y N Comments
Fever
q q
Contagious Illness
q q
Edema with Pregnancy
q q
Suspicious Growths/Moles
q q
Open Wounds and Bruises
q q
Cancer/History of Cancer
q q
Active Herpes
q q
The following is a list of cautionary conditions which practitioners need to be aware of in order to provide you with the
safest possible massage session. Please indicate if any are applicable to you. Your Practitioner will review with you.
Y N Comments
High Blood Pressure
q q
Varicose Veins
q q
Circulatory Disorders
q q
Respiratory Disorders
q q
Digestive Disorders
q q
Pregnancy
q q
Diabetes
q q
Osteoporosis/Arthritic Conditions
q q
Inflammation
q q
Additional Comments:
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