Aroma Thai
Client Health Intake Form
Please complete this form before your treatment
Personal Information
Conditions
Please tick if any of the following apply:
Medical Information
Are you taking any medications?
Are you currently pregnant?
Do you suffer from chronic pain?
Massage Information
Have you had a professional massage before?
What type of massage are you seeking?
What pressure do you prefer?
Do you have any allergies or sensitivities?
Select any areas you do NOT want massaged:
Front
Back
None selected
Declaration & Signature
Please understand that after any treatment depending on how deep you could be sore and possibly bruised for up to a week.
I hereby Certify that the above is true and correct and that I am physically capable of receiving the Massage treatment.
On the assumption that the above details are correct Aroma Thai, its servants, employees or agents are not Responsible if any injury or health issues are incurred if the medical information provided is incorrect.
Therapist Section
To be completed by the therapist after consultation