Personal Information

Your name (first last)

Your email

Date of Birth (dd-mm-yyyy)

Gender
MaleFemaleOther

_______________________________

About your massage

Have you had a professional massage before?
NoRareRegularly

What type of massage would you like?
TherapeuticRelaxationCombinationOther (describe below)

Provide any information about what kind of massage you would like:

What kind of pressure do you prefer?
LightMediumDeep

_______________________________

Lifestyle

What best describes your work environment?
SedentaryPhysical workMixed

Does your job involve repetitive motions (e.g., typing, lifting, or standing in one position)?
YesNo

Do you experience discomfort related to your work activities?
Not at allRarelyFrequently

Do you do exercises (Gym, Sport)?
NoRarelyRegularly

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Medical Information

Do you have a musculoskeletal condition that you want to address?
(If not, leave blank)
Neck, Shoulders tensionLow Back PainMuscle or Nerve PainStrain, SprainOther

Have you had any traumas?
NoMinorMVAExtensive

Do you have any illnesses?
NoHigh blood pressureDiabetesCancerHeart DiseaseHepatitisTuberculosisHIVOther

If you have anything to add or clarify, please do it here (optional):

Do you have any Allergies (particularly to dogs and plants)?
NoYes (please, specify above)