Peace Massage Studio
Swedish Medical Center
701 East Hampden Ave., Suite 225
Englewood, CO 80113
303-750-0159

All therapeutic massage treatments are by appointment only. Outcall appointments are limited to elderly clients or persons with disabilities, and involve an extra charge for travel.

I will make every effort to accommodate your time schedule. Currently, I have appointment slots available Tuesday through Sunday, from 10 AM to 6PM. Planning for your massage in advance is optimal, as it offers you an opportunity to include some quiet time, with lots of water, after your treatment. This is important, because you are worth it!

Please Note: If you are a new client, and have not had the opportunity or time to complete the health history questionnaire found below, please plan on arriving 10-15 minutes before your scheduled appointment.

You are welcome to complete the following form to contact me. You will receive a response within 24-48 hours. Feel free to call, should you wish a more prompt response, and/or to book an appointment.

This questionnaire is to help me provide you with the best professional care & service in advance of your appointment. If you are a new client, completing all of the fields will expedite your first appointment. However, only the "name" field below is required.

I look forward to hearing from you to schedule a session!

Complete only those fields that you feel comfortable answering.
All information in this form is kept confidential.

Name (required):
Client status:	Current client New client
Phone:
Email Address:
Mailing Address:
Date of birth:
Referred by (or how you learned about Peace Massage):
Occupation:
Do you wear contacts?	Yes No
Do you wear dentures?	Yes No
Current medications:
Are you currently under a doctor's care? If so, please provide details.
Any previous injuries, such as broken bones, sprains, strains, whiplash, etc? If so, please explain:
Recent surgeries? If yes, please explain:
Please check if you have any of the following:	headaches backaches tightness in jaw grinding teeth neck pain injuries infections allergies high blood pressure low blood pressure bruises arthritis skin problems any known blood clots contagious diseases
(Women only) Are you pregnant?	Yes No
(Women only) If so, how many months?
Describe your dietary habits:	Good Fair Need Improvement
Do you smoke?	Yes No
Have you received professional massage or bodywork before?	Yes No
If so, when?
On a scale of 1 to 10, what's your stress level right now? (1 is low; 10 is high)	1 2 3 4 5 6 7 8 9 10 Optional comment:
Describe your massage/bodywork goals:
Do you feel that you “hold” stress or tension in any part of your body? If so, is it:	Occasional Frequent
Please describe any areas of current discomfort or pain. Please also indicate any areas where you may be experiencing stress or tension:
What kind of pressure do you prefer?	Light Medium Firm Various
If necessary, explain:
Emergency contact (name and phone):
Which days work best for you:	Tuesday Wednesday Thursday Friday Saturday Sunday
Which times work best for you:	Early morning Mid morning Noon Early afternoon Late afternoon Evening
Additional information regarding preferred appointment days or times:
Best way to reach you:	Phone Email
Best time to reach you:	Anytime Morning Afternoon Evening
Additional information/message for Susan:

create form