MASSAGE TREATMENT

CLIENT DETAILS

Full name

Phone

Email

Birthday

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Health Information

What is the state of your health?

What is the reason for your treatment?

What areas of your body require most attention?

What areas of your body do you feel pain, if any?

Anything else you think we should be aware of?

Have you had massage treatments before?

Yes

No

Are you pregnant?

Yes

No

Do you exercise regularly?

Yes

No

Do you take vitamin supplements?

Yes

No

Do you smoke?

Yes

No

Do you take any medication?

Yes

No

I have completed the details above to the best of my knowledge and agree to the treatment I have requested.

Today's Date

Signature

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