Relax & Unwind















Medical Information
Are you taking any medications? YesNo

Are you currently pregnant? YesNo


Do you suffer from chronic pain? YesNo



Have you had any orthopedic injuries? YesNo

Please indicate any of the following that apply to you CancerHeadaches/MigrainesArthritisDiabetesJoint Replacement(s)High/Low Blood PressureNeuropathyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or Strains

Massage Information
Have you had a professional massage before? YesNo
What type of massage are you seeking? RelaxationTherapeutic/Deep Tissue

What pressure do you prefer? LightMediumDeep
Do you have any allergies or sensitivities? YesNo

Are there any areas (feet, face, abdomen, etc.) you do not want massaged? YesNo