Name __________________________________________*

State _______ Zip _____________* Massage Time Time _____________ Date _____________ Day _____________

Telephone # _______________________*

Optional* E-mail address: __________________________________ *

Have you had any serious or chronic illness, operations, or traumatic accidents? _____________________

If yes, please explain: _____________________________________________________________________

Are you currently, or have you at any time within the last 12 months been under the care of a physician?

If so, for what condition?_____________________________________________________________

I have completed this health form to the best of my knowledge and consent to receive massage therapy. I understand that massage therapy is a therapeutic health aid and is non-sexual. I UNDERSTAND THAT MASSAGE THERAPISTS DO NOT DIAGNOSE ILLNESS, DISEASE OR ANY PHYSICAL OR MENTAL DISORDER; NOR DO THEY PRESCRIBE MEDICAL TREATMENT, PHARMACEUTICALS, OR PERFORM SPINAL THRUST MANIPULATIONS. I ACKNOWLEDGE THAT MASSAGE IS NOT A SUBSTITUTE FOR MEDICAL EXAMINATIONS OR DIAGNOSIS, AND THAT IT IS RECOMMENDED THAT I SEE A PRIMARY HEALTH CARE PROVIDER FOR THAT SERVICE.