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Therapy Assessment Form
Main Concern *
Recovery
Stress
Mobility
Relaxation
Area Affected *
Neck
Shoulder
Upper Back
Lower Back
Hip
Leg / Calf
Knee
Foot
Other
How long have you been facing this issue? *
Select
Few Days
Few Weeks
Few Months
More Than 1 Year
Pain Level *
1
2
3
4
5
6
7
8
9
10
Selected Pain Level: 1/10
Mild (1-4)
Moderate (5-8)
Severe (9-10)
Medical Conditions
Diabetes
High Blood Pressure
Asthma / Breathing Issue
Heart Condition
None
Currently Under Medical Treatment? *
Yes
No
Are you pregnant? *
Yes
No
Anything therapist should know? *
Yes
No
Have you consumed food/drinks recently?
Taken massage therapy before?
Experienced discomfort during previous sessions?
I consent to the clinic collecting and using my information.
Submit Assessment