Fran Coys Salon & Spa - Massage Therapy Guest Questionaire
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New Massage Guest |
Date
_________ |
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Update* |
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Name ___________________________________ Occupation ___________________________
Physician’s Name __________________________
Phone ( __)_____________________________ Cell / Other (___) ________________________
Emergency Contact
_______________________________
* Medical information needs to be updated annually.
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Medical
Information |
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| Please check all that apply |
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Contagious
Disease |
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Surgery |
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Athlete’s Foot |
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Diabetes |
o
Cancer |
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Osteoporosis |
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Frequent
Headaches |
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Arthritis |
o
Asthma |
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Muscle Spasms |
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Dizziness |
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Fatigue |
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Numbness /
Tingling |
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Herniated disc |
o
Chronic Back
Pain |
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Stress |
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Thrombosis |
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Joint Swelling |
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Glasses /
Contacts |
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Allergies |
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Pregnancy |
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High Blood
Pressure |
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Insomnia |
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Sinus Trouble |
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Epilepsy /
Seizures |
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Heart Problems |
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TMJ Dysfunction |
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Circulatory
Problems |
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Frequent
Bruising |
o
Fibromyalgia |
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Varicose Veins |
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Recent Broken
Bones |
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Depression |
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On Medication |
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Circulatory
Problems |
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Are you on any medications? Please list ___________________________________________________
_________________________________________________________________________________
Additional comments
_________________________________________________________________
I understand that the massage/body treatment 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 practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. Because
massage/body treatments should not be performed under certain medical conditions, I affirm that I have stated
all my known medical conditions. I agree to keep the practitioner updated as to any changes in my medical profile
and understand that there shall be no liability on the practitioner’s part
should I fail to do so.
Client Signature* _________________________________ Date _________________
*Parent if under 18 years of age.
Practitioner Signature
_____________________________ Date _________________