Client Intake

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Client Intake

Medical History and Agreement

Name *

Address *

Telephone *

Birthdate *

YYYY

Occupation *

Please read carefully.

Massage Therapy is contra-indicated for certain medical conditions.

Check all that apply: *

Allergies

Aneurysm

Anxiety

Arthritis/Gout

Asthma

Autoimmune Disorders

Blood Clots/Thrombosis

High Blood Pressure

Bursitis

Cancer

Chronic Pain

Circulatory Problems

Contagious Disease/Infection

Depression

Diabetes

Digestion/Elimination Problems

Edema/Swelling

Emphysema

Epilepsy/Seizures

Fibromyalgia

Headaches/Migraines

Heart Condition

Infection

Injury

Jaw Pain (TMJD)

Joint Replacement

Kidney Disfunction

Liver Disorders

Neuropathy

Numbness/Tingling

Osteoporosis

Paralysis

Phlebitis/Varicose Veins

Pregnancy

Rashes/Skin Conditions

Sinus Problems

Stroke

Surgery of any kind

Tondonitis

None

Have you or anyone you have been in close contact with been tested positive for COVID-19?

Are you exhibiting any symptoms of COVID-19 such as dry cough, shortness of breath, fever, rash, diarrhea, lack of taste or smell within the last 14 days?

Other:

Required

Please explain any conditions checked above. *

Please list any medications you are currently taking. *

All questions have been answered honestly to the best of my knowledge. *

Yes

I understand that my failure to share medical information releases all liability from my practitioner. *

Yes

I understand and agree to the 24 hour Cancellation Policy. *

Yes

I understand and agree to the No Tolerance Policy. *

Yes

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