Massage Therapy Intake
I understand that if I have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from my primary care provider may be required prior to service being provided. I understand that the massage/bodywork I receive is for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during my session(s) I will immediately inform the practitioner. I further understand that massage/bodywork is not a medical examination, diagnosis, or treatment and I should see a physician or qualified medical specialist for any medical or physical illness. Massage/bodywork should not be performed under certain medical conditions. I affirm that I have stated all of my known medical conditions and answered all questions honestly. I will keep the practitioner updated as to any changes to my medical profile. It is also understood 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 full payment of that session.

By typing your name and date below you agree to the statement above and all the information below is truthful.

Date
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First & Last Name
Birthdate
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Complete address (with City, State, Zip Code)
Phone #
Email address
How many 8oz glasses of water do you consume daily?
Occupation
Sports/exercise activities you currently participate in
Please list any areas of tenderness, pain, swelling? Please explain
Any recent (within the past 5 years) surgeries? Please explain.
What areas of the body have been a concern for you in the past? Please explain.
When was the last time you received a professional massage?
Who have you seen in the past for massage therapy?
Please list any allergies
Please list current medications
Please check any areas of concern for me:
Required
Referred by anyone? Please list their name.
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This form was created inside of Synergy Within Wellness. - Terms of Service - Additional Terms