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Massage Treatment Record & Client Feedback Form

1.Client Information

Birthday
Month
Day
Year

2. Pain Level Assessment

Please rate your pain or discomfort before and after this massage session.

(0 = No pain, 10 = Most severe)

Body Area Before Treatment After Treatment

Neck Before Treatment 0=No pain, 10 = Most severe
Neck After Treatment 0=No pain, 10 = Most severe
Shoulders Before Treatment 0=No pain, 10 = Most severe
Shoulders After Treatment 0=No pain, 10 = Most severe
Upper Back Before Treatment 0=No pain, 10 = Most severe
Upper Back After Treatment 0=No pain, 10 = Most severe
Lower Back Before Treatment 0=No pain, 10 = Most severe
Lower Back After Treatment 0=No pain, 10 = Most severe
Hips Before Treatment 0=No pain, 10 = Most severe
Hips After Treatment 0=No pain, 10 = Most severe
Legs Before Treatment 0=No pain, 10 = Most severe
Legs After Treatment 0=No pain, 10 = Most severe
Other Before Treatment 0=No pain, 10 = Most severe
Other After Treatment 0=No pain, 10 = Most severe

3. Post-Treatment Effect

Please tick the option that best describes how you feel after the massage:

4. Satisfaction Rating

Please rate your experience today (1 = Poor, 5 = Excellent)

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Located in Sydney CBD – Thai Remedial Massage using 2 thumbs only, no tools.  
Tel: 0422 786 924 

Email: info@nswremedialmassage.com.au  
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​ABN 19 104 038 745

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