La Vie's Hours

Monday9am - 8pm
Tuesday9am - 6pm
Wednesday9am - 6pm
Thursday9am - 8pm
Friday9am - 6pm
Saturday9am - 4pm
SundayClosed

Senior Massage (65+) - Services

Senior Massage (65+)

Options available:

  • One Hour - 50 (One Hour)

To Save Time Please Fill Out This Form Prior To Appointment. Thank You!

Name:
Email Address:
Have you ever recieved a professional massage or Reflexology? Yes
No
 
Date of last massage/reflexology
Are you currently on any medication? Yes
No
 
Please list current medications, including aspirin, ibuprofen, etc.
What do you expect from your massage or reflexology today?
Medical History Surgeries? Year? Treatment Recieved?
Accidents?
Health History.. Excercise None
Moderate
Daily
Weekly
Heavy
 
Work Activity? Sitting
Standing
Light Labor
Heavy Labor
 
Health History Smoking, Packs a day?
Alcohol, Drinks/wk
Caffeine, cups/day
Stress/ Reason?
Hepatitis A, B or C HIV/AIDS? Yes
No
 
Allergies? Yes
No
 
Other Yes
No
 
Lupus Yes
No
 
Jaw Pain/TMJ Yes
No
 
Stiffness Yes
No
 
Spasms/Cramps Yes
No
 
Headaches/Head Injuries Yes
No
 
Painful Feet Yes
No
 
Lower Back/Hip/Leg Pain Yes
No
 
Sprains/Strains Yes
No
 
Arthritis Yes
No
 
Bone or joint disease/injury? Yes
No
 
Tendonitis Yes
No
 
Bursitis Yes
No
 
Broken/Fractured Bones Yes
No
 
Circulatory Heart condition Yes
No
 
Allergies Yes
No
 
Sinus Problems Yes
No
 
Breathing Difficulty Yes
No
 
Lymphedema Yes
No
 
High Blood Pressure Yes
No
 
Blood Clots Yes
No
 
Varicose Veins Yes
No
 
Reproductive Pregnant
PMS
Other
 
Other Yes
No
 
Skin Allergies Yes
No
 
Warts Yes
No
 
Athletes Foot Yes
No
 
Rashes Yes
No
 
Other Yes
No
 
Nervous System Numbness/Tingling Yes
No
 
Fatigue Yes
No
 
Sleep Disorders Yes
No
 
Chronic Pain Yes
No
 
Other Yes
No
 
Digestive Irritable Bowel Syndrome Yes
No
 
Gas/ Bloating Yes
No
 
Diverticulitis Yes
No
 
Other Yes
No
 
Moderate Discomfort Yes
No
 
Tolerable but intense discomfort Yes
No
 
Depression Yes
No
 
Eating Disorders Yes
No
 
Diabetes Yes
No
 
Cancer/Tumors Yes
No
 
Slight Sensitivity Or Superficial Tension? Yes
No
 
Others...... Corn Yes
No
 
Hammer Toe Yes
No
 
Bunion Yes
No
 
Ingrown Nail Yes
No
 
Changes in Tissue Texture Yes
No
 
Explain any OTHERS, in above questions.