Massage & Manual Therapy Intake
Sign in to Google to save your progress. Learn more
Name *
Date of birth *
MM
/
DD
/
YYYY
Address
City
State
ZIP code
Home phone
Cell phone *
Occupation *
Age
Gender
Clear selection
How did you hear about us
Emergency contact name
Emergency contact phone number
Please indicate if you have any of the following conditions; certain medications and health problems may be contraindicated for massage. If necessary, a physicians release may be required from your primary care provider. *
Yes
No
Diabetes
Frequent headaches
Arthritis
High blood pressure
Epilepsy or seizures
Joint swelling
Varicose veins
Contagious disease
Osteoporosis
Allergies
Back pain
Knee Pain
Other joint pain
Surgery
Frequent numbness or tingling
Pregnant
Recent injury
Allergy to lotion or oils
If yes to above, please explain
Please list any medications you are currently taking *
Please list any supplements you are taking *
Please list any other medical conditions you may suffer from not listed above *
Describe any symptoms you are currently experiencing *
Check which types of therapy you have tried for this problem(s) *
Required
Check which exercise activities are currently part of your weekly routine *
Required
Please explain (type, frquency, duration) of any of the above exercise activities
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. *
If I experience any pain or discomfort during the session I will immediately inform the practitioner so that the pressure and or strokes may be adjusted to my level of comfort. *
I understand that massage or bodywork should not be considered a substitute for medical care. *
I agree to keep the practitioner updated on any changes in my medical profile and understand that there should be no liability on the practitioners part if I fail to do so. *
I understand that session charges will not be refunded. *
I understand that same day cancellations incur a $40 fee. *
I understand that any illicit or sexually aggressive remarks or advances made will result in immediate termination of the session and I will still be liable for payment of the scheduled appointment. *
I affirm that I have stated all of my known medical conditions and have answered all questions honestly. *
Client Digital Signature (first name & last name) *
Date of digital signature *
MM
/
DD
/
YYYY
Digital Signature of Parent or guardian (if under 18)
Date of digital signature
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This content is neither created nor endorsed by Google.