AIR'G Massage Landsdale

Welcome to AIR'G Massage!

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Personal Information

Client Name

Date Of Birth

Phone Number

Email Address

Occupation

Address

Emergency Contact

Contact Name

Contact Phone Number

Relationship

Personal Habits / Lifestyle

Caffeine / Tea

/ day

Water / L

/ day

Alcohol

Cigarettes / Pcs

/ day

Average Hours Of Sleep Per Night

hours

Exercise Habits

General Diet

Rate Overall Stress Level

Low Low-medium Medium High

Medical History

Under Medical Under Therapeutic Treatment Bone/Joint issue Sprain/Soft Tissue Osteoporosis Arthritis Headaches Sleep disorder Cancer

Heart Condition Varicose Veins Blood clots High/Low blood pressure Breathing difficulties Sinus problem Hay Fever Asthma

Allergies Skin disorder Constipation Bloating Pregnancy Diabetes Epilepsy Lymphatic system

If any of the above have been ticked, please give details

Do you currently have any medical condition not listed above?

Yes No

List any medication, supplements, or vitamins you take regularly:

Yes No

Have you had recent surgery (in the last 12 months) on the area to be treated?

Yes No

Do you suffer from pain?

Yes No

Massage Information

Have you had professional massage before?

Yes No

What type of massage are you seeking:

Relaxation Deep Tissue Remedial

What type of massage pressure do you prefer?

What is your goal for this treatment session?

Please indicate where you have areas of discomfort on the picture

Confirmation

By signing below, you agree to the following. I acknowledge that I am aware of the benefits and risks of massage therapy, and 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.

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