Name________________________________________________Age__________

Address____________________________________________________________

Profession______________________Telephone_________________Weight______

How did you come to want to receive a____________________________________

Have you received massage before?______When? How often?__________________

How is your relationship to water?  Any hobbies in water, like swimming, diving, sailing?

___________________________________________________________________

___________________________________________________________________

Have you ever experienced any traumas in water, recent or past?__________________

___________________________________________________________________

Do you have any health conditions, injuries or sensitivities?_______________________

 fever over 100 degrees  urinary tract infec.  uncontrolled blood pressure

 uncontrolled epilepsy  respir. tract infec.  heart considerations

 cardiac failure  blood infection  cerebral hemorrhage

 significant open wounds  tracheostomy  multiple sclerosis

 respiratory disease--vital  bowel incontinence  chlorine sensitivity

 capacity less than 1500 cm2  infectious disease  recent surgery

Have you ever had any difficulties with your neck or back, such as whiplash or slipped discs?

___________________________________________________________________

Any tendency toward motion sickness, in cars or boats, for instance? ___________________________________________________________________

Are you in the care of a doctor or therapist?_________________________________

Do you take medications? Drugs? ________________________________________

Signature_______________________________________   Date_______________

© 1996 Alexander Georgeakopoulos

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