Massage Therapy Consent Form

Health Questionnaire

Massage therapist

Today's Date

Month

Day

Year

First name

Last name

Address

Gender

Man

Woman

Non-binary

Birthday

Month

Day

Year

Phone

Email

How did you hear about us?

Reason for consultation

PERSON TO CONTACT IN CASE OF EMERGENCY

Full Name & Phone Number

HEALTH QUESTIONNAIRE

Occupation

Name of your doctor

Do you have a massage therapy insurance plan?

Yes

No

If yes, Name of insurer

Do you take any medications?

Yes

No

If yes, specify

Do you suffer from chronic pain?

Yes

No

If yes, specify which ones

Have you been the victim of a bad fall or accident?

Yes

No

If yes, specify the context

Have you ever had surgery(ies)?

Yes

No

If yes, specify which one(s)

Is there anything else we should know about your health?

Yes

No

If yes, specify

CONTRAINDICATIONS

Are you pregnant?

Yes

No

If yes, since when?

Have you ever received a massage?

Yes

No

What type of pressure do you prefer?

Light

Average

Deep

Specify the parts of the body where you do not want to receive a massage (example: face, abdomen, feet)

What are your expectations during this treatment?

I agree to the

Signature

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terms & conditions

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MendiTherapy

Massage Therapy Consent Form

Health Questionnaire