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Pre-Treatment Health Declaration

Please fill out the following health declaration form in order to participate in treatment with any of our therapists.

Personal Information

Medical Information

Do you suffer from any of the following:

Cancer, Headaches/Migraines, Arthritis, Diabetes, Joint Replacement(s), High/Low Blood Pressure, Neuropathy, Fibromyalgia, Stroke, Heart Attack, Kidney Disfunction, Blood Clots, Numbness, Sprains / Strains ?

Are you currently pregnant? 

(If yes please detail how far along and any risk factors below)

Do you suffer with chronic pain? 

(If yes please detail below and explain what makes it better / worse.)

Massage Information

Thanks for submitting!

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