New Client Massage Therapy Readiness Questionnaire

Massage and bodywork services can do wonders for your mind and body – provides pain relief, rehabilitation, relaxation or rejuvenation (physical or mental). As a nationally certified practitioner, I have made a commitment to providing you with the highest quality of care. Keeping your health, well-being and safety in mind there are a few things I need to know during scheduled bodywork sessions, including:

Contact Information
Name (required)
City (required)
State
Preferred Phone (required)
E-mail (required)

General Health
Are you taking any new medicine (prescription or over the counter)?	Yes No
Have you recently been or are you currently sick (cold, flu, etc.)?	Yes No
Have you had any recent injuries?	Yes No
Have you recently had any surgery?	Yes No
Is there anything else about your general health that has changed?	Yes No
If female, are you pregnant? If yes, what trimester are you in?

For more information about National Certification or massage and bodywork safety, visit the National Certification Board for Therapeutic Massage and Bodywork's Web site at www.ncbtmb.com.

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