Massage Evolved - - Client Intake Form
Please fill out the following form to the best of your ability. This form will allow us to prepare for your massage appointment and gain knowledge to streamline our pre-massage consultation.
First and Last Name
Occupation (this helps us understand any stress your body may be under)
Referred by (ie. Google, Yelp, friend, or other)
How often do you receive massage?
Rarely ( <1 per year)
Sometimes (when needed for pain or special occasion)
Often (monthly or more frequent)
What kind of pressure do you prefer? (check as many as apply)
Light (generally used with elderly, touch sensitive or those who find gentle touch relaxing)
Areas you wish to have avoided in your massage:
What would you like this session to focus on? (ie. areas of pain or tension, exercise recovery, work-related posture issues, stress relief, relaxation, general tension)
Are you currently pregnant or think you may be pregnant?
If you're pregnant, what week of pregnancy are you in?
Please list any health conditions or recent injuries/surgeries that may affect your massage session (ie. allergies beyond seasonal, scent sensitivity, arthritis, current skin issues, uncontrolled blood pressure or diabetes, varicose veins, history of blood clots, seizures, recent new medications, limited range of motion/mobility, hyper mobility, medical or cosmetic implants, diabetic pumps, medical ports, etc.)
By filling out this form, you understand that the massage/bodywork you receive is provided for the purpose of relaxation and relief of muscular tension. You further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that you should see a physician, chiropractor, or other qualified medical specialist if you are seeking a diagnosis. You understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments. Massage/ bodywork should not be performed under certain medical conditions, you affirm that you have stated all your known medical conditions and answered all questions honestly. You agree to keep the practitioner updated as to any changes in your medical profile and understand that there shall be no liability on the practitioner’s part should you fail to do so.
Yes, I agree to the above terms
If you experience any pain or discomfort during this session, you will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to your level of comfort. At any point and for any reason, the client may ask to end the massage and the practitioner immediately end the session.
Yes, I agree with the above terms
You understand that proper draping will be used throughout the session. The practitioner shall not engage in massage of breast tissue of female clients without written consent. The client also understands that any illicit or sexually suggestive remarks, advances, or movements made by the client will result in immediate termination of the session, and the client will be liable for payment of the scheduled appointment.
Yes, I agree with the above terms
By typing my legal name below, I agree to that the above answers are completed to the best of my knowledge.
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