RegisterTherapist NotesPersonal InformationUsernameE-mail AddressPasswordConfirm PasswordFirst NameLast NamePhoneWould you like to be notified of special promotions and offers?YesNoHow did you hear about us?Medical InformationDo you have any difficulty lying on your front, back, or side?YesNoIf yes, please explainDo you have any allergies to oils, lotions, or ointments?YesNoIf yes, please explain?Do you have sensitive skin?YesNoDo you sit for long hours at a workstation, computer, or driving?YesNoWhat type of massage are you here for?Traditional Thai or Thai YogaReflexologySwedishHot StoneDeep TissueCombinationAshiatsu(Back-walking)Body ScrubCBDAroma TherapyPlease select any areas of discomfort on the front of your body.Head - LeftHead - RightShoulder - LeftShoulder - RightArm - LeftArm - RightChest - LeftChest - RightAbs - LeftAbs - RightUpper Leg - LeftLower Leg - RightPlease select any areas of discomfort on your back:Head - LeftHead - RightShoulder - LeftShoulder - RightArm - LeftArm - RightUpper Back - LeftUpper Back - RightLower Back - LeftLower Back - RightUpper Leg - LeftUpper Leg - RightCalf - LeftCalf - RightWhat pressure do you prefer?LightMediumDeepMassage InformationAre you currently under medical supervision any injury, disease, or illness?YesNoIf yes, please list:Do you see a chiropractor?YesNoIf yes, how often?Please check any condition listed below that applies to you:contagious skin conditionopen sores or woundseasy bruisingosteoporosisrecent surgeryartificial jointsprins/strainsallergies/sensitivityheart conditionhigh or low blood pressurecirculatory disordervaricose veinsatherosclerosisphlebitisdeep vein thrombosis/blood Clotsjoint disorder/rheumatoid arthritis/osteoarthritis/tendonitisdiabetesepilepsyheadaches/migrainescancerback/neck problemsFibromyalgiaTMJcarpal tunnel syndrometennis elbowpregnancy if yes how many months?Please list any conditions not shown aboveIs there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.Client Signature: Only fill in if you are not human Login