CLIENT INFORMATION AND RELEASE FORM

PERSONAL INFORMATION *

GENERAL AND MEDICAL INFORMATION

Have you ever had a professional massage session? *

Yes

No

Do you frequently suffer from stress? *

Yes

No

Do you experience frequent headaches? *

Yes

No

Are you pregnant? *

Yes

No

Are you wearing contact lenses? *

Yes

No

Are you diabetic? *

Yes

No

Do you have high blood pressure? *

Yes

No

Are you epileptic? *

Yes

No

Have you ever had surgery? *

Yes

No

Have you had broken bones in the past 2 years? *

Yes

No

Do you have cardiac or circulatory problems? *

Yes

No

Do you suffer from back pain? *

Yes

No

Do you experience numbness or stabbing pains? *

Yes

No