Personal Information First Name Last Name Gender - None -MaleFemale Date of Birth Email Phone Home Address Occupation Massage Information Do you want stretches included in your massages? yes no What Activities Therapies Have You Found Helpful for Your Lifestyle? What Activities Therapies Have You Found Helpful for Your Lifestyle? Chiropratic Nutritionist Yoga Running Walking Weight Training Pilates Massage Meditation Swimming Sports Dance Other... Other... Enter other... Medications you are currently using What results do you want from your treatments? General Relaxation Relief From Pain More Range-of-Motion Decrease Stress Please list your injures Are you sensitive to Scents? Do you have any allergies? Are you sensitive to Scents? Do you have any allergies? No Yes List Allergies/Sensitivities Have you ever had a massage before - None -yesno Your music preference Classical Nature Sound Jazz Bamboo Flute Will Provide Own Areas of Your Body that You Hold Tension or Stress Areas of Your Body that You Hold Tension or Stress Head Face Shoulders Neck Upper Back Mid Back Low Back Abdomen Hips Chest Arms Hands Front of Legs Back of Legs Feet Other... Enter other... Which area or areas do prefer NOT to be worked on? Which area or areas do prefer NOT to be worked on? Head Face Neck Arms Back Glutes Legs Feet Other... Enter other... Where did you hear about? Where did you hear about? Search Brochure Referral Groupon Other... Enter other... I understand... I understand that I need to give exactly 24 hours or more for cancellation or I will forfeit payment, I cannot give my massage to anyone else last minute (less than 24 hours). I understand that if I would like to receive a treatment from the same therapist I will contact Revive Message Therapy and not the Therapist directly. I understand that I need to book a massage at least 24 hours in advance.