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Body Pain Chart
Registered Massage Therapy
FOR YOUR INFORMATION:
An accurate health history is important to ensure that it is safe for you to receive massage treatment. If your health status changes in the future, please
let me know. All information gathered for this treatment is confidential except as required or allowed by law or except to facilitate diagnosis
(assessment) or treatment. You will be asked to provide written authorization for release of any information.
Last Name First Name
FREE FLOW MASSAGE THERAPY CLINIC
Bradley Newstead, RMT
125 Sutherland Drive
Kingston, ON K7K 5V6
613-536-0300
613-561-0274 (text)
Date
Additional Info
Shade the areas where you are experiencing pain, aching, burning or tension on the diagram below.
R
R
L
L
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