514-696-0024
Phone:
Date of birth
Occupation
Do you engage in hobbies or recreational activities?
YesNo
Do you practice any sports?
Have you ever received a massage before?
Approximate Date
What type of massage?
SwedishCalifornianShiatsuTrager MDKinesitherapyHot StoneOther
What do you prefer during a massage?
What brings you to massage therapy?
What are you feeling?
TensionPainNumbness
Since when?
Do you suffer from an injury or inflammation?
Have you consulted a healthcare professional about this?
Are you currently being treated / Have you been treated?
Are you pregnant?
Expected due date
High-risk pregnancyNausea
Is your menstrual cycle:
PainfulPMSMenopausalHot flashesMigraines
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