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BEST FOR YOU MASSAGE, L.L.C.
WELCOME!
ABOUT THE THERAPIST
SERVICES OFFERED
WHAT TO EXPECT!
CONSENT FORM
BROWSE PRICES/PURCHASE MASSAGE
BOOK AN APPOINTMENT
GET A FREE MASSAGE!
CONTACT US
NEWSLETTER SIGNUP
CLIENT ONLINE INTAKE FORM
VISIT OUR BLOG
HOLIDAY GIFTCARDS ARE HERE
Our Satisfied Customers
Business of Year Award
Corona virus tips
WELCOME!
ABOUT THE THERAPIST
SERVICES OFFERED
WHAT TO EXPECT!
CONSENT FORM
BROWSE PRICES/PURCHASE MASSAGE
BOOK AN APPOINTMENT
GET A FREE MASSAGE!
CONTACT US
NEWSLETTER SIGNUP
CLIENT ONLINE INTAKE FORM
VISIT OUR BLOG
HOLIDAY GIFTCARDS ARE HERE
Our Satisfied Customers
Business of Year Award
Corona virus tips
PLEASE COMPLETE PRIOR TO YOUR FIRST VISIT.
The following information will be used to help plan safe and effective massage sessions. Click on arrows to make a choice and blanks without arrows allow a typed response. QUESTIONS WITH RED ASTERISK ARE REQUIRED.
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Please answer the questions to the best of your knowledge. Please ask for assistance if needed. CLICK on SUBMIT Button when completed.
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Indicates required field
First Name
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Middle Initial
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Last Name
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DATE OF BIRTH
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Email
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How did you hear about us:
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BUSINESS CARD
BROCHURE
NEWSPAPER
WORD OF MOUTH
REFERRAL
WEBSITE
GOOGLE
WEBSEARCH
YELLOW PAGES
SIGN
Phone Number
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GENDER
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Male
Female
AGE
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Address
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Line 1
Line 2
City
State
Zip Code
Country
CURRENT WEIGHT IN POUNDS
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HEIGHT FT/INCH
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TYPE IN FEET AND INCHES
Are you taking any medications?
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Yes
No
If so can you list them or bring in a list?
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EVER HAD A PROFESSIONAL MASSAGE?
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YES
NO
IF YES, HOW OFTEN?
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DO YOU EXPERIENCE STRESS IN ANY ASPECT OF YOUR LIFE?
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YES
NO
IF YES, HOW DOES THAT STRESS EFFECT YOU?
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DO YOU CURRENTLY SEE A CHIROPRACTOR
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YES
NO
IF YES, HOW OFTEN?
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DO YOU HAVE PROBLEMS LYING IN ANY OF THESE POSITION? PLEASE CHECK IF SO.
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ABDOMEN
BACK
RIGHT SIDE
LEFT SIDE
None
DO YOU HAVE ANY MEDICATION ALLERGIES? IF SO, PLEASE LIST.
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DO YOU HAVE ANY ALLERGIES TO OILS, LOTIONS, OR OINTMENTS?
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OILS
LOTIONS
OINTMENTS
None
DO YOU SIT FOR LONG HOURS AT A WORKSTATION, COMPUTER, DRIVING, ETC?
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YES
NO
IF YES, PLEASE DESCRIBE.
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DO YOU PERFORM REPETITIVE MOTION DAILY OR OFTEN?Choose One
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YES
NO
IF YES, PLEASE EXPLAIN.
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DO YOU HAVE ANY MEDICALS IMPLANTS?
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YES
NO
IF YES, PLEASE EXPLAIN.
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HAVE YOU HAD A MASTECTOMY? IF YES PLEASE SPECIFY:
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RIGHT
LEFT
BILATERAL
None
DO YOU HAVE SENSITIVE SKIN?
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YES
NO
ARE YOU WEARING CONTACTS?
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YES
NO
DO YOU EXPERIENCE PAIN OR DISCOMFORT?
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YES
NO
IF YES, PLEASE EXPLAIN.
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PLEASE CHECK ANY OF THE MEDICAL PROBLEMS YOU MAY HAVE:
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TENDONITIS
OSTEOPOROSIS
EPILEPSY/SEIZURES
HEADACHE/MIGRAINE
CANCER
DIABETES
DECREASED SENSATION/NUMBNESS
BACK/NECK PROBLEMS
FIBROMYALGIA
TMJ
CARPAL TUNNEL SYNDROME
TENNIS ELBOW
PREGNANCY
HIGH BLOOD PRESSURE/HYPERTENSION
LOW BLOOD PRESSURE/HYPOTENSION
SKIN CONDITIONS/RASHES
BLEEDING PROBLEMS
HEART CONDITION
BLOOD CLOTS/HISTORY OF BLOOD CLOTS
KIDNEY FAILURE
MEDICAL IMPLANTS
None
PLEASE EXPLAIN ANY CONDITION CHECKED ABOVE.
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ARE YOU CURRENTLY UNDER MEDICAL SUPERVISION?
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YES
NO
IF YES, PLEASE EXPLAIN.
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Submit