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RECEIVING A MASSAGE
READ OVER THIS FORM A COUPLE OF TIMES BEFORE YOU RECEIVE YOUR MASSAGE

Act like this was your first professional massage and do not tell the therapist that you are going to massage school.
Ask the therapist for a one-hour relaxing massage.
Fill out the questionnaire as soon as you are done receiving the massage.
Try to go into detail about every question.
Try to stay awake during the massage.
Go to a place you have not been before.
Be quiet for a while when you are receiving the massage.
Get a business card before you leave and staple it to the questionnaire.
Have all the areas massaged that are involved in a full-body massage.
The majority of the questions are “yes and no” answers, please explain further if you can.

BEFORE THE TREATMENT

1. Where did you receive your massage: Health club___ Chiropractic office___ Hospital___ Salon___ Private
Practice___ At your home___ At their home___ Hotel___ Massage School___ or other______________________?
2. What was the therapist full name (the name of the therapist will not be shared with anybody in the class)
___________________
3. Did you: Call for an appointment____ Have someone else make the appointment for you___ or walk in to make an appointment?
4. What was the price of a 1-hour massage:
less that $30__ $30__ $35__ $40__ $45__ $50__ $55__ $60__ $65__ $70__ more than $70__
5. If you called for an appointment, did they explain whom it is with: yes___ no___ did not call___?
6. If you called, did the person on the phone explain to come early to fill out a health form: yes___ no___ did not call___?
7. Was your therapist a: male_____ female_____?
8. If you called for an appointment were the directions, they gave you: easy to find___ hard to find___ knew were it was before___?
9. Ask how long have they been practicing_______________?
10. Ask where they went to school for massage training _________?
11. What city did you receive your massage in ________________?

12. Did the therapist introduce herself or himself to you: yes__ no__?
13. Did the therapist say your name when you arrived: yes__ no__?
14. Did the therapist seem nervous: yes__ no__?
15. Did the therapist seem professional: yes__ no__?
16. Did you fill out a health form: yes__ no__?
17. Did the therapist go over the health form with you and ask questions: a lot__ little__ no__?
18. Do you think there could have been more questions on the health form: yes___ no___?
19. Was there a question on the health if you wear contacts or glasses: yes__ no__?
20. Did your massage start: on time___, late___ little earlier___?
21. What kind of environment was the massage clinic: relaxing_____ stressful______ average_____?
22. Was the place clean: yes___ no___?
23. Did the therapist explain what a full-body massage entails: yes__ just a little__ no__?
24. Did the therapist explain how they drape: yes___ no___?
25. Did the therapist use: sheets___ towels___ sheet and blanket____ to drape you?
26. Did the massage table feel like there was extra padding on the table: yes___ no___?
27. Did the therapist ask if you needed to use the restroom before the massage: yes__ no__ went on your own__?
28. Did the therapist call the massage table a: bed_____ table_____?
29. Did the therapist explain to get under the sheets: yes___ no__?
30. Did the therapist give you an option if you wanted to start supine or prone: yes__ no__?
31. Did the therapist tell you were to put your clothes and jewelry: yes__ no__?
32. How far did the therapist tell you to dress down to: underwear__ what you feel comfortable with___ or did not explain___?
33. Did the therapist knock or ask to come in before he/she entered: yes__ no__?
34. Did the therapist wear shoes: yes__ no__ and what kind______?
35. Did the therapist ask if you are allergic to anything: yes__ no__ on the health form__?
36. Was the therapist friendly: yes__ no__?
37. If the therapist had long hair: long hair down__ long hair up__ short hair__?
38. Was the therapist nails cut: yes__ no__?
39. The music was: too loud__ or soft__ just right__ no music at all__?
40. Did the therapist have you read a “client bill of rights”: yes__ no__?
41. Did you sign a “Client’s Bill of Rights” (C.A.M. LAW): yes__ no__?
42. Did the therapist offer stomach massage: yes__ no__?
43. Did the therapist offer breast massage: yes__ no__?
44. Did the therapist offer glute massage: yes__ no__?
45. Did the therapist ask if he/she could massage your scalp: yes__ no__?
46. What did the sheets smell like: oil___ clean___ Perfume___?
47. Was the therapist’s sleeves: short___ long___ or long and not rolled up___?
48. Could you see any other client’s files lying around: yes__ no___?
49. Did the therapist have any cuts or open areas on their hands or forearms: yes__ no__?
50. Did the therapist have any jewelry on their hands or wrists: yes__ no__?
51. Look to see if they have liability insurance anywhere visible: yes__ no__?
52. Look to see if they have their diploma anywhere visible: yes__ no__?
53. Was there oil stains on the walls or carpet: yes___ no___?
54. Did the sheets on the table look stained: yes___ no___?
55. Was there a clock in the massage room: yes___, no___?
56. Did the therapist have pictures of their family: yes___ no___?
57. Did the therapist have a name tag: yes___ no___?
58. Was the therapist’s shirt: tucked in___ or out___?


DURING THE TREATMENT

1. Did the therapist ever go under the sheet: yes___ no___?
2. Was the headrest adjustable: yes___ no___?
3. Was the table wide enough: yes____ no____?
4. Did the therapist offer you a bolster: yes___ no___?
5. Did the therapist adjust or take out the bolster before you turned: yes___ no___?
6. Did the massage table have an armrest: yes___ no___?
7. Did the therapist go into detail about their personal life: yes___ no___?
8. Did the therapist ever talk about sex, religion, race or any other things that are inappropriate: yes___ no___ if yes explain_____________________________________________?
9. Did the therapist work on only the areas that they said they would work on: yes___ no___?
10. Did the therapist have the oil bottle: under the table___ on the table___ on a shelf___ or in a holster___?
11. Could you hear the therapist breathing: yes___ no___?
12. Was the therapist quiet when you did not want to speak: yes___ most of the time___ no___?
13. Could you feel the therapist’s nails: yes___ no___?
14. Were the therapist’s hands cold to start: yes___ no___?
15. Did the therapist breath smell: yes___ no___?
16. Did the therapist have body odor: yes___ no___?
17. Were there any scents in the massage room: yes___ no___?
18. Did the therapist have any perfume on: yes___ no___?
19. Did the therapist have gum or candy in their mouth: yes___ no___?
20. Was the massage table heated: yes___ no___?
21. Did the therapist ever go to your feet to your face without washing their hands: yes___ no___ started with the face___?
22. Did the therapist use: oil___ massage lotion___ on your body?
23. If you wore underwear, did the therapist tuck the sheet into your underwear:
before asking____ did not ask____ did not tuck them in____ did not wear underwear____?
24. Did you hear any change in the therapist’s pockets while you were receiving your massage: yes___ no__?
25. Did you hear other people or sounds while you were getting a massage: no____ little____ a lot____?
26. Was the massage room: really dark_____ some light_____ or a lot of light_____?
27. Could you feel a draft when the therapist was draping you: yes___ no___?
28. Could you feel the therapist breath when the therapist was draping you: yes___ no___?
29. Did you feel comfortable with the way the therapist draped you: yes___ no___?
30. How much of the quads and hamstrings were exposed: ½___ ¾___ or all___?
31. Was the room: too cold___ or too hot__?
32. Did the therapist ask you at any time if the room temperature was comfortable: yes___ no___?
33. Did the therapist check in with you about the amount of pressure given: yes___ no___?
34. Did the therapist keep contact with you almost all the time and did they leave body contact to get oil or go to the other side of your body: yes___ no___?
35. Was the massage a full-hour from the time they laid their hands on you, to the time they took them off you: more than___ less than___ one hour___?
36. Did the therapist ask you if you wanted to relax after the massage and how long: yes___ no___?
37. If you have tattoos, did the therapist comment on them: yes___ no___ did not have tattoos___?
38. If you have moles, did the therapist mention anything about them: yes____ no____ did not have any____?
39. If you have scars, did the therapist mention anything about them: yes____ no____ did not have any____?
40. Did the therapist warm the area up before they started to go deeper: yes___ no___?
41. Did the therapist use scented oils without checking with you first: yes___ no___?
42. When the therapist worked on your upper chest: yes___ no___?
43. Did the therapist work your glutes: with the sheet on__ partly draped__ sheet totally off__ or did not even work them__?
44. Did the therapist use: oil___ lotion___ or nothing___ on your face?
45. Did the therapist say anything about energy work: yes__ no__?
46. Did the therapist do any energy work without asking: yes___ no___?
47. Did the therapist ever get on their knees: a lot___ little___ or never___?
48. Did the therapist ever sit on the table: a lot___ little___ or never___?
49. Did the therapist ever sit in a chair: a lot___ little___ or never___?
50. Did the therapist use each strokes at least 3 times: most of the time__ some of the time__ hardly ever__?
51. Could you feel their shirt or any other part of their body: yes___ no___?
52. Was the therapist using proper body mechanics when you were supine: most of the time__ or not much__?
53. Did the therapist ever tell you, to let them know if the pressure was too light or too deep: yes___ no___?
54. Was there a rhythmic flow with the massage: most of the time___ not much___ never___?
55. Could you recognize any strokes they were using: a lot___ some___ hardly any___?
56. Did you think the therapist used: too much oil___ or too little oil___?
57. Did the therapist ever name any muscles during the massage: yes___ no___?


AFTER THE TREATMENT

1. Did the therapist give you a glass of water after the massage: yes___ no___?
2. Did the therapist tell you to drink a lot of water after the massage: yes___ no___?
3. Did the therapist recommend anything for you to do after the massage: yes___ no___ if yes then what___________________?
4. Did the therapist ask you to schedule another appointment: yes___ no___?
5. Did the therapist explain to come back on a regular basis (ex. 1X week/ 4 weeks = evaluation): yes__ no__?
6. Did the therapist diagnosis anything: yes___ no___ if yes then what_________________?
7. Did you tip the therapist: nothing__ $1-$5__$6-$10__, more than $10__?
8. Did the therapist try to sell you anything: yes___ no___?
9. Did the therapist answer any questions you had: yes___ no____?
10. How long were you there, from the time you walked in the door to the time you left: 1 hour__ 1:15__ 1:30__?
11. Would you ever get a massage from that therapist again: yes___ no___?
12. Would you recommend other people to go to that therapist: yes___ no___?
13. Did the therapist give you a business card before you left: yes___ no___?
14. Did the therapist wipe off the excess oil when your massage was done: yes___ no___?
15. Was there a mirror to fix your hair in the massage room: yes__ no__?
16. Did the therapist meet you right after the massage: yes___ no__?
17. Did the therapist offer any: cold packs__ or hot packs__ nothing__?
18. Did the therapist tell you to get up slow after the massage: yes___ no___?
19. Did the therapist explain that you might have side effects after the massage: yes__ no__?

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