Massage Questionnaire

Please complete this form so we can plan for your specific massage requests.

First name please:

e-mail Address:

Date you would like your Massage Session?

Time you would like your massage session?

Have you had a professional massage before:

If yes, approximately how many times?

Do you prefer a Male or Female Massage Therapist:

Do you have any medical conditions, are you pregnant, or have any physical problems with your body (injuries or otherwise) that the therapist should be aware of?
(If "yes" the Therapist will ask you to explain during the pre-massage interview.)

Are you taking any prescription medications for problems such as Diabetes, Heart problems, high blood pressure, epilepsy or seizures, etc.

Have you been in an accident or broken any bones in the last 2 years?

Your massage will be a "full body massage" all areas include Gluteus Maximus - (butt), Pecks, Lower Stomach, Etc Is there any of these areas you do not want to included?
(If "Yes" the Therapist will ask you during the pre-massage interview which areas to avoid.)

Do you want you face done?

Are there any areas of your body that you would like the therapist to focus more time on during the massage (i.e. face, scalp, neck, shoulders, upper back, lower back, arms, hands, gluteus, pecks, legs, feet, etc).
( If "yes" the Therapist will ask you about those areas during the pre-massage interview.)

Optionally, is it OK if the draping is removed for the Gluteus area?

What massage pressure do you prefer?

What style or type of massage would you like to have?
(Read these descriptions before answering: Massage Techniques)
Swedish Massage
Trigger Point
Sensual Massage
Deep Tissue Massage
Combination Massage
Reflexology

If you have selected Combination Massage or Sensual Massage, using a scale of 1 to 5 with 5 being more,
how tantalizing would you like the massage to be?

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