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Massage Treatment – Client Record Card

Client Details: *

First

Last

Date of Birth *//

Gender *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Email *

Emergency Contact Person *

First

Last

Emergency Contact Number *

Do you exercise regularly? *

Describe your energy level *

Describe your stress level *

Sleep Pattern *

General State of Health *

Are you a smoker? *

Do you take any medication? *

Reason for visit

Do you have any discomfort, painful or sensitive areas to avoid? *

Any operations in the past two years? *

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? *

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 *

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.

Date *

Comment

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