Portland Serenity Massage

Name:

Date of Birth:

Address:

City, State, Zip:

Occupation:

Email:

Reffered By:

What are you goals for massage therapy?:
For example: general stress relief, decrease pain and tightness in feet and ankles, and improve range of motion in left shoulder
Please list all areas with chronic problems:
For example: pain in back, wrist stiffness, limited movement in hips, swelling of feet, numbness in fingers
Please list any regular physical activities that you notice impact your body:
For example: heavy lifting at work, jogging, sitting at a desk, caring for children, playing soccer
Please list any regular activities that you do to relax:
For example: yoga, art, meditation, reading, exercise
Please list all recent injuries, and any major past injuries, surgeries, or health conditions:

Please list all medications, supplements, vitamins you are currently taking:

If you are currently under the care of a physician, please include your physician's contact information:

Please list any allergies or sensitivities:

Please check any that apply:

Regular Headaches:

Skin condition:

Contagious disease :

Fibromyalgia:

Jaw pain/TMJ:

Diabetes:

High blood pressure :

Heart disease:

Blood clots :

Vericose viens:

Arthritis:

Immune compromised :

Epilepsy:

Cancer:

Stroke:

Pregnancy:

Please provide more information on your health condition(s):

Is there anything else you would like to share?:

Do you have any questions?: