Name
*
First Name
Last Name
Email
*
Pronouns
Gender
Date of Birth
Have you had a professional massage before?
Was there anything you really liked or really did not like about your past massage experiences?
What drew you to seeking out massage therapy?
What are your primary goals in working together?
How much pressure do you prefer?
What health related issues do you have/ have you had in the past?
Medications currently or previously used (over the counter and prescription). For each medication, please list: a) the medication, b) the dosage, c) how long, and d) reason for taking.
Please list any other practitioners you are currently working with (type of pracitioner and name)
Do any of these practitioners offer sliding scale?
Passions/ Interests / Hobbies
Occupation
How long have you held this job?
Side hustle or creative endeavors that contribute financially?
How do you use your body at work?
Annual Income
Previous Occupations
Have you had or do you experience any of the following?
Is there a blood family/ generational history of any of the above?
Other conditions
Are you allergic or sensitive to any substance (medications, nuts, oils, fruit, pollens)?
Have you had any surgeries? If so, for what reasons? Please describe any complications:
Typical Bedtime
Typical hours asleep
Do you feel rested upon waking?
What food and/or flavors do you crave?
Supplements/Vitamins/Herbs currently or previously used
Please check any health issues you've had in the past or are currently experiencing
How would you rate your stress level as of late?
Do you have practices, tools, support systems, etc that you lean on in times of stress? If so, what helps?
Are you interested in herbal recommendations and/or services?
This could include drinking an herbal tea, taking a tincture, using a topic oil, or having a separate one-on-one conversation about herbs, diet and lifestyle beyond your massage session.
Please list any major events in the last five years of your life (or further back if it seems significant) and rough dates they occurred. Include events such as births, deaths, marriages, divorces, accidents, moves, job changes, illnesses and anything else you feel greatly impacted your life.
Is there anything else affecting your health right now that you would like me to know about?
What is bringing you joy as of late?