Eco Chateau Massage Wellness Questionnaire

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First Name *

Last Name *

Address *

City *

State *

Zip Code *

Phone *

Email *

Birthdate *

YYYY

How did you hear about us? (If a friend referred you, tell us who so we can thank them!) *

Have you ever received a professional massage before? *

What pressure do you prefer for massage?

Please list any medications you are currently taking and reasons for them:

What are your goals/expectations for this therapy session?

Please review this list and check any conditions that apply to you:

Frequent headaches

Currently pregnant (If so, massage can only be performed in the second and third trimesters)

Arthritis

High blood pressure

Epilepsy or seizures

Varicose veins

Contagious disease/illness

Osteoporosis

Bruise easily

Diabetes

Cardiac or circulatory problems

Numbness or stabbing pains

Please list any allergies:

Do you have a sensitivity to touch or application of pressure in any area? If yes, please explain:

Have you had any surgery, broken bones, disc herniation or any falls resulting in a serious injury or any other injuries that the therapist should be aware of? If yes, please explain:

I understand that although massage therapy can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis or treatment. Being that a massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully and am able to receive massage therapy. If changes in my health occur, I will update Eco Chateau Wellness Spa. This is a professional therapeutic massage and any sexual remarks or advances will terminate the session immediately and I will be liable for full payment of the scheduled treatment. If I am unable to make my scheduled appointment, I will provide a 24-hour cancellation notice by phone or email. If I miss my scheduled appointment or cancel less than 24 hours before my scheduled appointment, I agree to pay the late cancel fee of $40. By checking the box below, I do hereby waive and release the massage therapist from all liability- past, present and future. *

I agree

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