Telephone: Home cel Work
Is this the first massage you have ever had? If not, how many have you had?
How did you hear about me?
Date of birth: Height: Weight:
How much stress are you under? Low Medium High Very High
What do you do to cope, ro relax, or to just feel better ordinarily?
Assign percentages according to the extent to which you tend to be (or what percentage of the time do you tend to be):
2) sensitive and feel emotions strongly:
3) involved in thinking a lot, making plans and organizing things mentally:
Does your diet exclude anything in particular? If so, what?
Do you engage in any form of exercise, sport, or yoga? If so, what and how often?
Are you currently seeing a doctor (or chiropractor or other health practitioner) for any specific condition or concern? If so, what?
Have you ever had surgery? If so, for what and when?
Have you had or do you currently suffer from:
Heart disease Ulcers
High blood pressure Liver disorder
Arthritis Migraine headaches
Kidney disease Cancer
Asthma Hepatitis B or Hepatitis C
Diabetes Severe depression
Anemia Musculo-skeletal injuries
Are you pregnant now?
Do you have children? If so, how many? What are their names and ages?
Do you wear contact lenses?
Are you ticklish? If so, where?
What areas of your body in particular are painful, sore, or do you carrly a lot of tension in?
What do you hope to get out of today's session?
Do you have any long term goals for massage therapy?
I understand that it is my responsibility to alert my massage therapist, Dr. Randa Sununu to any physical condition which might affect this work. I, , hereby waive and release my massage therapist, Dr. Randa Sununu, from all liability as a result of the treatments performed on me.
Furthermore, I understand that Long Life Massage has a 24 hour cancellation policy, and that if an appointment is cancelled with less than 24 hours notice prior to an appointment, I, , agree to pay in full for the missed session.