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Mirembe Massage Therapy Client Form
Please fill out the form prior to your first appointment. more information at
mirembemassageplanet.com
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Name
Your answer
Email
Your answer
Phone number
Your answer
Address
Your answer
What are your primary reasons for your appointment?
Your answer
Have you had a massage before?
Yes
No
Other:
Are you pregnant?
yes
no
Clear selection
Please check all that apply
Skin condition-rash, warts, hives, skin cancer, other
Cancer, in treatment or in remission.
Lymphatic condition-swollen gland, nasal congestion, lymph edema
Joint problems/stiffness-arthritis, sacroiliac problems, TMJ, other
Bone Condition-osteoporosis, fracture, other
Frequent and/or Intense Headaches
Recent injury or accident-whiplash, sprain, bruise, other
Numbness/Tingling, Sciatica
Tendonitis, Bursitis
Diabetes
IUD
Bruises easily
Chronic Back Pain
Recent surgery
Chronic Fatique/ Often Tired
Heart Problems
Circulatory Condition-high blood pressure, varicose veins, blood clots
Pain Radiating Down Arms or Legs
Chronic Tension
Allergies/ Sensitivity to Any Oils/ Other Ingredients
Other:
Please explain checked areas and list any other medical condition of which I should be aware.
Your answer
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