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Massage
Questionnaire ( Not to be filled out Online)
Professional (Non-Sexual) Massage Therapy for Men & Women
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Name :
__________________________________________________________________ |
| Address
:
________________________________________________________________ |
| City :
___________________ |
State :
_________________ |
Zip
:_____________________ |
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| Email :
___________________________________________________________________ |
| Phone(home):____________ |
Phone(work):_____________ |
Phone(mobile):____________ |
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| Occupation :
_________________________ |
Birth Date :
_________________________ |
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Have you
had a professional massage before, and if so, approximately how
many times?
_______________________________________________________________________ |
Do you
have any physical problems with your body (injuries or
otherwise) or any areas
of acute pain or inflammations / disesase (incl. varicose veins
/ arthritis / joint swelling,
osteoporosis, ) that I should be conscious of or avoid before
giving you the massage?
__________________________________________________________________________ |
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?
__________________________________________________________________________ |
Are
there any areas that I should avoid when giving you a massage,
either for medical
reasons, or because you bruise easily, or for personal reasons
(i.e. the gluteus maximus - butt)?
__________________________________________________________________________ |
Are
there any areas of your body that you would like me to focus
more time on during
the massage (face, scalp, neck, shoulders, upper back, lower
back, arms, hands, gluteals, legs, feet…).
__________________________________________________________________________ |
| Pressure: |
Soft / Light touch :
______________________ |
Med / Firm touch :
______________________ |
Hard / Deep touch :
_____________________ |
Where
did you see my ad?
__________________________________________________________________________ |
End of Massage |
What
part of the massage did you find particularly therapeutic or
stress relieving
(enjoy the most)?
__________________________________________________________________________ |
What
part of the massage did you enjoy least or were any techniques
expected or desired that you did not receive?
__________________________________________________________________________ |
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