Massage Therapy Client Questionnaire Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Date:

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  Name:

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  D.

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  Gender:

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  S.

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  M.

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  Address:

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  Home Phone:

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  Work Phone:

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  Occupation:

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  Referred by:

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  Have you had a professional massage prior to this visit?

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  Reason for therapeutic massage (major complaint):

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  What, if any, treatment have you had for this condition?

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  Is there anything that makes your condition worse?

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  Please note if you are currently being treated by any of the following practitioners:

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  Medical Doctor (MD) or Nurse Practitioner (NP)

• 

  Release:

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  Chiropractor

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  Release:

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  Psychiatrist

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  Release:

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  Have you had any surgery?

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  (If yes, please explain.

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  Emergency Contact Name & Relation to You:

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  Phone:

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  Desired Massage Pressure:

• 

  Sleeping Position:

• ...and More!