Massage Health Form

Please complete this form before your massage. This information helps ensure the treatment is safe and appropriate for you.

All details will be kept private and confidential.

Feel free to leave any fields that don’t apply to you blank.

Ngā mihi!

Contact Information

First & Last name

Phone

Birthday

Day

Month

Year

Please tell me about any medical conditions I should be aware of

Heart or circulation issues (e.g. high/low blood pressure, DVT, varicose veins, blood thinners)
Spine, joint, or muscle concerns (injuries, chronic pain, implants)
Respiratory, metabolic, or neurological conditions (e.g. asthma, diabetes, epilepsy, neuropathy)
Skin conditions (cuts, rashes, eczema, infections)
Recent surgery, vaccination (last 48 hours), or illness
Cancer in the last 5 years

Please list any crucial medications and their purposes

No medication

Other

If relevant, could you be pregnant?

Yes

Any cultural preferences you'd like me to be aware of?

Anything else you would like me to know?

Consent

By submitting this form, I confirm that the information is accurate and I will update the therapist of any changes to my health.

Massage Policy

I have read and agree to the Massage Policy.