Massage Intake Form

Name:______________________________________________________     Date of Birth:_________________

Address:_________________________________________________  City:_______________  Zip:___________

Cell Phone #:____________________________  Home Ph #:____________________________________

Email:_________________________ Employer/Occupation:_____________________________________

Would you like to receive a reminder for your appointment via: (Please Circle) Txt  or Phone  Yes / No

Are you over the age of 18?  Yes / No  *If, No a parental consent form must be presented prior to the massage.

Emergency Contact (Name, Ph #, Relationship):______________________________________________

Primary Reason for the Appointment:______________________________________________________

  1. Have you ever had a professional massage before? Y / N   If yes, how long ago?________________
  2. Are you under the care of a medical practitioner? Y / N   If yes, what kind?____________________
  3. Are you taking any medications? Y / N  If Yes, please list here:______________________________

________________________________________________________________________________

  1. Pressure preference:  Light    Medium    Deep

Before Treatment:

Have you had any injuries, surgeries, or other medical condition(s) in the past that may influence today’s treatment? Y / N  Please list:_______________________________________________________________

Please mark “C” for Current or “P” for Past for the following health conditions if they apply to you:

____ Blood Clotting Disorders                        ____ Back or Neck Discomfort / Injury

____Circulatory / Heart Disorder                        ____Car Accident(s) Date:___________

____High Blood Pressure                                ____Varicose Veins

____Muscle Cramping                                ____Anemia

____Cancer                                        ____Headaches

____Skin Conditions                                ____Nausea

____Respiratory Problems                                ____Fainting/Dizziness

____Digestive Disorders                                ____Epilepsy

____Numbness / Tingling                                ____TB/other communicable diseases

____Herniated Discs                                ____Diabetes ( Type1 / Type 2 ) Neuropathy

____Arthritis / Bursitis                                ____Fractures or other bone trauma or Scoliosis

____Jaw Pain                                        ____Neurological Issues

Are you allergic to any essences or oils?  Y / N

Are you wearing contact lenses?  Y / N

Are you wearing dentures?  Y / N

Have you had alcohol today?  Y / N

Are you pregnant?  Y / N   If yes, how many months:_______________________

To make sure we say “Thank you!”, please let us know if you were referred by anyone:

Name:__________________________________________________

Consent for Treatment:

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said during the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Signature:________________________________________________    Date:_____________________

Parent or Guardian Signature (in case of a minor):________________________________________________   Date:____________

NOTES (For Therapist use only):