Email Address *

Type of Massgae You Would Like

Please check the areas of the body you would like worked on during the massage?

Feet

Head

Neck

Shoulders

Face

Chest

Hips

Hands

Arms

Back

Legs

Glutes

On a scale of 1 to 10 how much pressure would you like during the massage?

1

2

3

4

5

6

7

8

9

10

Are you feeling pain in any particular area of the body?

Please Describe Your Area of Pain (*if applicable)

Do you have or have you had any of the following conditions? Check appropriate boxes.

High Blood Pressure

Stiff Neck

Recent Surgery

Low Blood Pressure

Whiplash

Fractures

Heart Condition

Serious Accident

Recent Fever

Nervous Condition

Varicose Veins

Arthritis

Eating Disorders

Any Contagious Disease

Inflammation

Diabetes

Internal Organ Dysfunction

Insomnia

Epilepsy

HIV virus

Headaches

Cancer

Skin Disorders

Pregnancy

Decreased ROM

Allergies

Other

Do you have any problems laying on your back, front or sides?

Do you have any allergies or sensitivities to topical applications (lotions, oils, aromatherapy oils, etc.)

Do you sit for long periods of time at the office or driving?

Where do you hold the most tension in your body?

What areas of the body (using the list above) do you enjoy the most to be massaged?

Would you prefer a male or female masseues?

Female

Male

Any additional information, questions or comments that would be useful for your masseuse

YiA YOGA works with various massage therapists & body workers to ensure we have the perfect fit just for you. Please fill out the following form so we can best place you with the optimal treatment for your body & your current needs & desires.