Massage — MAW Kinetics

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DOB

Occupation

How did you hear about us

Referred? By who?

Medical History

Please note any previous injuries/illnesses

How do you manage stress?

Sports/exercise undertaken:

Do you have difficulty lying on your back or front?

Are there any areas that you would NOT like to have massaged? (feet, head)

What are your goals for this massage session?

How long has this been going on for?

Do you have any of the following affecting you: muscle tension, aches, pain? Please record the area on your body as well as areas that have limited movement or are painful to move

I certify that the above information is accurate. I agree to alert my practitioner of any physical/emotional changes as they occur. I also understand that 24 hour notice must be given if an appointment needs to be rescheduled, and that a missed appointment may incur charges that I must pay.

Client Signature

Please type your name

You may experience mild discomfort, headaches or tiredness after the massage. This is a normal cleansing response to flushing waste products from muscles that have been tense. Please contact me if you have any severe or ongoing effects after the massage or consult with your health practitioner if you have medical conditions that persist.

Client Information Sheet

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