Select Your Employee:

Shirley Thao

LMT

Select Your Services:

Have you received massages before? How recently? *

What are your areas of concern? *

Describe activities or movements that cause pain/discomfort or make it worse

How long have you had experience pain/discomfort in indicated areas?

What are your goals for the session today?

Do you have any injuries/surgeries? If so, please list them

Are you seeking treatment due to physician refferal?

Perferred pressure *

Please CHECK all that apply *

Any known allergies? Please specify *

Are you Pregnant? If so, how many months.

List any other health conditions or medications I should know about *

How many weeks/months are you? *

Do you have any medical/health conditions I should be aware of? *

Health History Form

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