Remedial / Holistic MassageSoft Tissue Therapy - Client Record Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Medical History Do you or have you had any of the following: High / low blood pressure Heart problems Diabetes Epilepsy Joint problems Skin problems/sensitivities Allergies Asthma If you answered 'yes' to any of the above please give details: Are you currently taking any medication or receiving any medical treatment? If so please give details: Do you or have you had any major surgery, accidents or serious illnesses? If so please give details: Is there any chance that you could be pregnant? Are there any specific issues that you would like the treatment to help? If so, please give details: What pressure do you prefer? Light Medium Deep Emergency Contact First Name Last Name Phone (###) ### #### Thank you!
