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Home
About Us
Services
New to MHS
Body Services
Facial Services
Massage Services
Waxing Services
MHS Packages
MHS Memberships
Med Spa
Med Spa Forms
Gallery
Photo Gallery
Video Gallery
Others
Blogs
Brochure
Team
Spa Etiquette & Policies
Menu
Home
About Us
Services
New to MHS
Body Services
Facial Services
Massage Services
Waxing Services
MHS Packages
MHS Memberships
Med Spa
Med Spa Forms
Gallery
Photo Gallery
Video Gallery
Others
Blogs
Brochure
Team
Spa Etiquette & Policies
Contact Us
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CLIENT PROFILE
Thank you for completing our client profile. This profile will assist us in identifying relevant medical or lifestyle information that may affect the service you have scheduled with us today and for your future visits.
Name
(Required)
First Name
Last Name
Phone
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Birthday
(Required)
MM slash DD slash YYYY
Email Address
(Required)
Occupation
Work Phone
Emergency Contact
(Required)
How did you hear about us?
(Required)
Please list anything you may be allergic to:
Are you pregnant or think you may be pregnant?
(Required)
Yes
No
If yes, how many months?
(Required)
Are you claustrophobic?
Yes
No
Do you have Diabetes?
Yes
No
Have you had a professional massage before?
(Required)
Yes
No
If yes, how often do you receive massage therapy?
(Required)
Do you have any difficulty lying on your front, back, or side?
(Required)
Yes
No
If yes, please explain
(Required)
Do you have any allergies to oils, lotions, or ointments?
(Required)
Yes
No
If yes, please explain
(Required)
Do you have sensitive skin?
Yes
No
Do you wear contact lenses, have dentures or us a hearing aid?
Yes
No
Do you sit for long hours at a workstation, computer, or driving?
Yes
No
If yes, please describe
(Required)
Do you perform any repetitive movement in your work, sports, or hobby?
Yes
No
If yes, please describe
(Required)
Do you experience stress in your work, family, or other aspect of your life?
Yes
No
If yes, please describe
(Required)
Is there an area of the body where you are experiencing tension,stiffness or discomfort?
Yes
No
If yes, please describe
(Required)
Are you currently under medical supervision?
Yes
No
If yes, please explain
(Required)
Do you see a chiropractor?
Yes
No
If yes, please explain
(Required)
Are you currently taking any medication?
Yes
No
If yes, please explain
(Required)
Please check any condition listed below that applies to you:
Contagious skin condition
Varicose veins
Recent accident or injury
Recent surgery
Sprains/Strains
Swollen glands
Circulatory disorder
Heart condition
Phlebitis
joint disorder / rheumatoid arthritis/osteoarthritis/tendonitis
epilepsy
cancer
decreased sensation
Fibromyalgia
carpal tunnel syndrome
Open sores or wounds
Easy bruising
Recent fracture
Artificial joint
Current fever
Allergies/Sensitivity
Atherosclerosis
High or low blood pressure
deep vein thrombosis/blood clots
osteoporosis
headaches/migraines
diabetes
back/neck problems
TMJ
Tennis elbow
Select All
Please explain any condition that you have marked above:
Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
Signed on the
(Required)
Date
(Required)
Month
Month
1
2
3
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12
Day
Day
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Year
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1927
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1925
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1920
Client’s Signature
(Required)
Printed Name
(Required)
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