Massage Form General InfomationFull Name * Date Of Birth (MM/DD/YY) * Sex *MaleFemale Weight (Kg) * Height (cm) * Email * Phone * Present Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry OccupationAre you interested in the nature of your work? *YesNo Would you describe your work as physical or mental? *PhysicalMental Do you have a lot of sitting work in front of a computer? *YesNo How Many Hours * Your NatureHow much importance do you give to personal cleanliness of body and clarity of mind? *LittleMediumGreat Importance Normally You Are *CalmTenseAnxiousIrritableJovial Gladly accepts the responsibility towards other members of family, friends and Colleagues? *YesNo Do you work with a sense of pride? *YesNo Personal ViewsTouchDo you feel you need the touch on your body to be *HardSoft Do you like hard touch on tense areas of the body *The top of the shoulderThe neckThe knee jointsThe ankle joints Do you like soft touch on soft skin areas of the body *Under sides of the armsInner thighsBreast bone or chest and rib cage SkinDo you have *Dry SkinOily SkinSensitive SkinNormal Skin Are you allergic with some kind of oil Are you allergic with some kind of aroma oil Massage( Morning Afternoon Evening )Do you have any kind of massage before this *YesNo Did you had massage from *ManWomanBoth On which body parts you need more attention * Do you like massage with *Ayurvedic oilAroma oilBoth Pregnancy (woman)Pregnant *YesNo Running Month * About first delivery NormalOperation Blood pressure NomalHighLow Any kind of Physiologycal problem * Any kind of postual problem * If you have problem with body movement * Are you doing yoga now a days *YesNo If you have some other problems Warnings on using massage (Do NOT TAKE MASSAGE WITHOUT A DOCTER CONSENT if )1. Inflammatory condition such varicose veins, thrombosis, or phlebitis. 2. Acute back pain, especially if the pain shoots down the arms or legs when touch the back. 3. Infection, bruising, or acute inflammation. 4. Contagious disease or epileptic 5. High fever. 6. Any other serious medical condition. PURPOSE OF MASSAGEWhy Do You Want Massage * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank Leave a Reply Cancel reply You must be logged in to post a comment.