Name *

First Name

Last Name

D.O.B. *

MM

DD

YYYY

Name *

First Name

Last Name

Have you previous had a hot stone massage? *

Yes

No

Have you had any serious health problems/major surgery with the last 12 months? *

Yes

No

Have you been under a dermatologists or physicians care? *

Yes

No

Do you wear contact lenses? *

Yes

No

Do you smoke? *

Yes

No

Please tick and provide detail if any of the following conditions refer to you:

Abdominal hernia

Asthma

Bacterial infection

Cancer

Coldsores/herpes

Fungal infection

Heart conditions

Loss of skin sensation

Low blood pressure

Parasitic infection

Post chemotherapy and radiation

Post herpetic neuralgia (shingles)

Post-surgery

Pregnancy

Prone to blood clots

Recent fractures

Skin legions, trauma, scars

Skin thinning

Sunburn

Under influence of drugs and alcohol

Viral infections

Contraindications

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Signature *

Acknowledgement that the above information is true and to the best of my knowledge. I will notify my massage therapist if there any changes to my health or medical condition.