Client FormsMassage Professionals of Jackson Hole

Full Name *

Date *

The following info will be used to plan a safe & effective massage session

Type of pressure you prefer *

LightMediumDeep

Are you currently taking any medications? *

YesNo

If Yes, Please list:

Do you have any allergies? (Including fragrances) *

YesNo

If Yes, Please List:

Do you CURRENTLY have any of the following:

Cold/FluOpen CutSevere PainBroken BonesHigh Blood PressureRashAnything ContagiousBruises/Sprains/StrainsHeart ConditionDiabetes

Please list ANY OTHER illness, disorder, injury, or medical conditions you have:

What are your goals / expectations for this therapy sessions?

Please list all areas of the body you wish to focus on today.

Draping will be used during the sessions - only the area being worked on will be uncovered. Informed Clients under age 18 must be accompanied by a parent or legal guardian during the entire session.

Terms *

I understand that the massage 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 therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage 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 should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in in my medical profile and understand that there shall be no liability on the therapist's part or the part of Massage Professionals of Jackson Hole should I fail to do so.