Name *

First Name

Last Name

Date of Birth *

Birthday

MM

DD

YYYY

How would you rate your diet and nutrition intake? *

Extremely healthy

Generally healthy

Needs improvement

Do you smoke? *

Yes

No

Have you ever smoked? *

Yes

No

Please check areas of concern *

Picture your body in both the front and back view and check all that apply.

Face

Chin

Neck/décolleté

Chest

Abdomen/Upper Belly

Abdomen/Lower Belly

Hips

From of Arms

Back of Arms

Front of thighs

Back of thighs

Glutes/buttocks

Upper back

Lower back

Sides aka 'love handles'

Other

Do you have any of the following today? *

Please check all that apply.

Sunburn

Headache

Asthma

Diabetes

Epilepsy

Depression

Hemophilia

Cuts, Burns, Bruises

Severe Pain

Arteriosclerosis

Varicose Veins

DIzziness

High Blood Pressure

Low Blood Pressure

Inflammation

Poison Ivy

Pregnancy

Hernia

Cancer

Contact Lenses

Muscoskeletal Problems

Irritated Skin Rash

Cold or Flu

Arthritis

Stomach Ulcers

Pins/Pacemaker

Heart Disease

None of the Above

Agreement *

I understand that massage is designed for the purpose of relaxation and relief from tension, muscle spasms, or poor circulation. The massage therapist cannot diagnose medical issues, diseases disorders or perform spine palpitations. Massage is not meant to be a cure for any medical conditions.

Yes

No