Name

First Name

Last Name

Is this your first professional massage?

If no, how frequently do you get treatments?

What do you hope to accomplish from today’s treatment?

Are you aware of any tension or pain in your body?

If so, where?

When did you first notice these problems?

YYYY

Is the problem constant or variable?

If variable, when and where does it happen?

What does it feel like? (Dull, Sharp, Achy, Burning, Throbbing, Numb, Etc):

Describe what activities cause this pain and/or make it worse:

Please rate your pain/discomfort:

Does this condition interfere with your normal daily function?

How?

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