We now have scientific proof of the benefits of massage - benefits ranging from treating chronic diseases and injuries to alleviating the growing trension of our modern lifestyles.  Having a massage does more than just relax your body and mind - there are specific physiological and psychological changes which occur.  When massage is utilized as a frequent, preventative therapy, and not as an occasional treat, it not only feels good, but can cure what ails you.
1.  What general benefits do you hope to achieve with massage?

1. What general benefits do you hope to achieve with massage?

Please choose as many as apply, from:
  • Relaxation
  • Stress Management
  • Injury Rehabilitation
  • Pain Management
  • Other, please specify


2.  What specific benefits are you hoping to achieve?

2. What specific benefits are you hoping to achieve?

Please choose as many as apply:
  • Relaxation & stress management
    • Improved attention span & concentration
    • Improved memory & creativity
    • Decreased anxiety
    • Improved sleep
  • Improved flexibility
  • Improved balance
    • Physical
    • Emotional
  • Increased energy & endurance
  • Decreased pain
  • Anti-aging benefits


3.  Please list all medications you currently take and the reason:

3. Please list all medications you currently take and the reason:

If you are on no medication, please type "none"

4.  What area(s) need improvement or you have a problem with:

4. What area(s) need improvement or you have a problem with:

  • Neck/shoulders
  • Hips
  • Legs
  • Low back
  • Mid back
  • Arms/wrists/elbows
  • Other (please specify)


5.  Please indicate any areas you experience numbness/tingling or pain:

5. Please indicate any areas you experience numbness/tingling or pain:

  • Arms/wrists/elbows
  • Back
  • Feet/legs
  • Neck/shoulders


6.  Do you find any part of a massage session especially helpful?

6. Do you find any part of a massage session especially helpful?

Please explain.

7.  Is there any part of your body you prefer not to be massaged?

7. Is there any part of your body you prefer not to be massaged?



Home  ·  About  ·  Contact Us
Copyright © Janet Lawlor, BCTMB