Bodyworks Massage Therapy - Certified Massage Therapist in Radford, VA

Bodyworks Massage Therapy Client Information

Client Name:

Today's Date:

Address:

City/State:

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Phone:

Email:

Date of Birth:

Occupation:

Employer:

Notify In Case of Emergency:	Phone:
How You Heard About Us:

Are You Pregnant? Yes No

Approx. Due Date:

Reason for Visit:

Current Illnesses/Injuries:	Recent Surgeries/Fractures:
Musculoskeletal Pain/Stiffness (low back, neck, shoulder, etc.):
Any Other Physical Or Emotional Difficulties:

Currently Under Medical Care? Yes No

For What Condition?

Current Medications:

Previous Bodywork? Yes No	How often?	Practitioner:
Goals For Your Session:
Type Of Bodywork Preferred: Swedish Deep Tissue Sports/Stretching Energy Work Other:

I agree that if at any time during my bodywork session, any type of sexually inappropriate language is used, or any type of sexual advance is made towards my massage therapist, my session will be immediately terminated, and full payment will be required.