Massage Therapy Questionnaire Our Story In The Media Our Team Join Our Team Contact Us Reviews Massage Therapy Questionnaire General InformationName* First Last Date* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*How were you referred to us?* Emergency Contact: Name and Phone Number* Physician: Name and Phone Number Occupation Date of Birth MM slash DD slash YYYY GenderFemaleMaleNon-BinaryThe reason for this session is:*Please list your major concerns and areas of focus:*Health HistoryAre you currently affected by any of the following conditions?Please check all that apply. Arthritis Back pain Bruise easily Cancer Diabetes Epilepsy/Seizures Headaches Heart problems High blood pressure Low blood pressure Muscle spasms Osteoporosis Pain in the legs/feet Recent injury/accident Skin problems Slipped disc Tendonitis TMJ Trouble sleeping Please list any medical conditions, health problems or physical conditions not listed:Please list any allergies:Are you currently taking any medication? If yes, please list:Are you pregnant?NoYesIf yes, how far along? Have you had surgery in the past five years?NoYesIf yes, please explain: Are you sensitive to touch?NoYesFurther comments:Please take a moment to carefully read the following information. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care physician may be required prior to service being provided.Consent* I agree to J.Con Salon and Spa's massage therapy policies and procedures.I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions and have answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and I will be liable for payment of the scheduled appointment.Electronic signature* First Last Electronic signature of Parent/GuardianConsent to treat a Minor: My electronic signature authorizes J.Con Salon and Spa's practitioner to administer massage, bodywork or somatic therapy techniques to my child or dependent as they deem necessary. First Last CAPTCHANameThis field is for validation purposes and should be left unchanged.