Case History Form

Your Name (required)

Your Address (required)

Your Email (required)

Your Phone Number (required)

Your Gender (required)
MaleFemale

Your Date of Birth (required)

Your Occupation (required)

Your Talking Preference (required)

Have you ever experienced a professional massage? (required)
NoYes

Do you have any of the following conditions?
Contagious diseaseFrequent headachesStressArthritisAllergiesCancerBack painBruise easilyDiabetesOsteoporosisWear contact lensesVaricose veinsCardiac or circulatory problemsDepressionPregnantJoint swellingEpilepsy or seizuresVery sensitive to touch or pressureNumbness or stabbing painsTension or soreness in a specific areaHigh blood pressureSurgery in the past five yearsAccident or suffered any injuries in the past two yearsBroken bonesOther medical conditions not listed

If yes, please explain below as clearly as possible.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis or treatment. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical profile during the session and understand that there shall be no liability on the massage therapist’s part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Registered Massage Therapist reserves the right to refuse to perform massage on anyone whom he/she deems to have a condition for which massage is contraindicated.

By submitting this form, I agree to the above statement