Please fill out this medical history questionnaire before your appointment. Fully listing medications and other health info helps us to keep you safe and comfortable during your session. Even if you do not think the info is relevant to massage or other services offered, having a full picture of your health is the safest and easiest way to ensure we are aware of any potential contraindications or adjustments that need to be made to your session.
Date of Birth
Do you have an autoimmune disease or inflammatory condition?
Do you have a history of trauma or PTSD that may affect your massage session?
Check any respiratory health conditions that apply:
Shortness of breath
Check any cardiovascular health conditions that apply:
Congestive Heart Failure (CHF)
Cerebral-vascular accident (stroke)
Low blood pressure
High blood pressure
Blood thinner usage
Check any skin conditions that apply
Parasitic infestation (lice/scabies/fleas)
Check any head/neck conditions that apply:
Jaw Pain (TMJD)
Tinnitus (ringing in ears)
Check any infectious conditions that apply:
Female-bodied clients- Please check conditions that apply:
Other pregnancy related conditions
Pelvic floor dysfunction/pain
Check any relevant soft tissue or joint dysfunction conditions:
Hypermobility or "double-jointed"
Surgery incision site
Joint repair/replacement surgery
Loss of sensation
Check any relevant neurological conditions that apply:
Multiple sclerosis (MS)
Traumatic brain injury
Please check other relevant conditions that apply:
Chrone's Disease/Ulcerative Collitis/IBS
If you selected "other" on the questions above, please provide additional info:
Have you ever had any major car wrecks or accidents that resulted in whiplash? Did you receive treatment at the time?
Have you had any surgeries or invasive procedures? If so, when? Do you have any ongoing symptoms as a result?
Please list all medications and supplements (including medical marijuana) you are currently taking (some medications can affect your massage experience. Your therapist needs this info to make sure you stay safe and comfortable during and after your session):
I have provided a full and accurate disclosure of my health information and current medications. I agree to update my therapist with any updates or changes in my health information before my treatment takes place in order to ensure my safety and comfort.
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