Hypnofascial Release & Massage Questionnaire Name * First Name Last Name Phone (###) ### #### Email * D.O.B Do you have any pre-existing injuries? * Yes No If yes, please give further detail (what, where, pain level, managment) Do you sit or stand for extended period of time each day? * Extended periods of sitting Extended periods of standing I get a good balance of both Do you perform any repetitive movement on a daily basis? If yes, please give further detail * Do you experience stress in your work, family or any other aspects of your life? * Yes No Are you allergic to any essential oils or lotions the therapist may use during your massage? If yes, please list below If yes, how do you think it has effected your health? Muscle tension/pain Anxiety Insomnia Irritability Thank you! Tanya will receive your form prior to your appointment.
