Register

Medical Information

Do you have any difficulty lying on your front, back, or side?

YesNo

If yes, please explain

Do you have any allergies to oils, lotions, or ointments?

YesNo

If yes, please explain?

Do you have sensitive skin?

YesNo

Do you sit for long hours at a workstation, computer, or driving?

YesNo

What type of massage are you here for?

Traditional Thai or Thai YogaReflexology

SwedishHot Stone

Deep TissueCombination

Ashiatsu(Back-walking)Body Scrub

CBDAroma Therapy

Please 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 - Right

Please 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 - Right

What pressure do you prefer?

LightMedium

Deep

Massage Information

Are you currently under medical supervision any injury, disease, or illness?

YesNo

If yes, please list:

Do you see a chiropractor?

YesNo

If 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 above

Is 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