Client/Patient Health Intake Form
One River Massage Therapy
45 Lyman Street, Suite 22
Westborough, MA 01581
508.203.1671 | info@onerivermassage.com
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First name *
Last name *
What name would you like us to address you by? *
Pronouns
Date of birth *
Street address *
Town/City *
State *
ZIP code *
Phone number *
Email address *
Occupation
Emergency contact information
Referred by
Please complete the following questions to the best of your ability. All information disclosed will be kept strictly confidential.
1.  Have you had professional massage before?
Clear selection
1a. Have you had Occupational Therapy or Physical Therapy recently?
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If yes, was there anything that you particularly liked or didn't like about these past therapies?
2.  Do you have any topical allergies or skin sensitivities to oils or lotions?
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If so, please explain.
3.  What physical activities do you do on a weekly basis?
4.  Do you sit for long hours at a workstation, computer, or while driving?
Clear selection
5.  Are you currently taking any medications, prescription or over-the-counter?
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If yes, please list the names of the medication(s)
6.  Please select any of the following health issues that you have had in the past year.
If other, please explain.
7.  Do you have cancer or a history of cancer?
Clear selection
8.  When were you first diagnosed with cancer?
9.  What type of cancer/stage?
10.  Where is/was it located?
11.  Are you being treated currently?
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If no, when was the date of your last treatment?
12.  What cancer treatments or surgeries have you undergone? Please supply details with dates and types of treatments and/or surgeries.
13.  What are your blood counts, if you know them?
14.  Has your treatment included any removal or irradiation of  lymph nodes?
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If yes or maybe, please describe.
15. Has your treatment included radiation therapy?
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If yes, please describe.
16.  Do you have any site restrictions due to any of the following:
If other, please describe.
17.  Do you have any pressure restrictions due to any of the following:
If other, please describe.
18.  Do you currently have any areas of swelling, edema, or tendency to swell?
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19.  Do you have any areas of numbness or altered sensation?
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20.  Do you have any areas of pain or tenderness?
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21.  Do you have any areas of infection?
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If you answered yes to any of questions 18-21, please list location and describe.
22.  Please list any surgeries you have had, including dates and description.
23.  Please list any injuries you have sustained, including dates and description.
24.  Is there anything else about your health history that you think would be useful for your therapist to know?
Consent for treatment:
If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the level of touch may be adjusted to my level of comfort. I understand that I will be asked questions regarding my physical state including present condition as well as past medical history. I understand that there are certain medical conditions for which massage therapy or occupational therapy would be contraindicated and that I may need to obtain written permission from my physician before receiving treatment. I understand that massage and occupational therapy practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, that nothing said in the course of the session given should be construed as such, and that it is recommended that I am concurrently working with my Primary Caregiver for any condition I may have. I verify that all information provided is correct and current to the best of my knowledge and will keep the therapist updated on any changes. All information disclosed will be kept strictly confidential by the therapists. I give my consent to receive therapeutic massage or occupational therapy services and will not hold my therapist or One River Massage Therapy responsible for any personal injury or loss of property.
Understanding all of this, I give my consent to receive care by typing my name below (if 18 or older). *
Consent of parent or guardian (type name below) if client/patient is under the age of 18.
Acknowledgment of cancellation policy:
We have a 24-hour cancellation/rescheduling policy. Appointments that are canceled or rescheduled within 24 hours of the scheduled session will result in a charge for the full price of the treatment session. However, if you are feeling ill, this cancellation policy does not apply and you will not be charged. In this circumstance, please contact us as soon as possible when you know you need to cancel your appointment. If you do not show up to your appointment and have not contacted us to cancel, your credit card will be charged the full appointment rate.
Client/Patient initials: *
Initials of parent or guardian if client/patient is under 18:
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