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Massage Treatment – Client Record Card
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Client Details:
*
First
Last
Date of Birth
*
DD
1
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MM
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2
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5
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9
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12
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YYYY
2024
2023
2022
2021
2020
2019
2018
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2016
2015
2014
2013
2012
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2010
2009
2008
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2006
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1941
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1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
-
Male
Female
Address
*
Address Line 1
City
State / Province / Region
Postal Code
Phone
*
Email
*
Emergency Contact Person
*
First
Last
Emergency Contact Number
*
Do you exercise regularly?
*
-
Yes
No
Are you pregnant or trying to conceive?
*
-
Yes
No
Describe your energy level
*
-
Low
Medium
High
Describe your stress level
*
-
Low
Medium
High
Sleep Pattern
*
-
8 hours or more
4-6 hours
General State of Health
*
-
Good
Average
Poor
Are you a smoker?
*
-
Yes
No
Do you take any medication?
*
-
Yes
No
Reason for visit
Do you have any discomfort, painful or sensitive areas to avoid?
*
-
Yes
No
Please state:
Any operations in the past two years?
*
-
Yes
No
Please state:
Please indicate any health condition you have currently
Please state if you are allergic to any skin products
What amount of massage pressure do you prefer?
*
-
Soft
Medium
Firm
Strong
GDPR Compliance - Check box
By completing this form, you agree to the storage and handling of your data by Sabai Sabai Traditional Thai Therapy
Client Signature
*
Clear Signature
I understand the massage therapy and other bodywork treatments given by Sabai Sabai Traditional Thai Therapy practitioner are for relaxation, stress reduction, relief from muscle pain and for increasing circulation. It has been made clear to me that massage and other body work is not a substitute for a medical examination or treatment. I understand that this is my choice to receive massage therapy and other body work treatment and I have provided accurate information concerning all my past and current health condition.
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