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Massage Intake Forms

Completing our intake forms will help us to best serve and assess your health needs so that we can provide you with optimal health services.  We will review your information to make sure there are no existing conditions that prevent receiving massage therapy services.  All information is kept confidential.  IMPORTANT:  PLEASE NOTE THAT THERE IS A SUBMIT BUTTON AFTER EACH PART; PLEASE BE SURE TO HIT THE SUBMIT BUTTON AFTER EACH PART.

MASSAGE INTAKE FORM - PART 1

First name:
Last name:
Email address:
Occupation:
Address 1:
City:
State:
Zip code:
Home Phone:
Work Phone:
Cell Phone
How did you find us?
Have you ever received massage therapy?
Type of massage experienced (swedish, shiatsu, deep tissue, etc.)
Are you currently taking any medications?
If yes, please list name and reason for medications
Are you currently seeing a healthcare professional?
If yes, please list names and reason/treatment
  

MASSAGE INTAKE FORM - PART 2

Do you have any of the following conditions past or present? If yes, please mark the correlating box with an "x"
arthritis
diabetes
blood clots
broken/dislocated bones
bruise easily
cancer
chronic pain
constipation/diarrhea
autoimmune condition
hepatitis (A, B, C, other)
skin conditions
stroke
surgery
TMJ disorder
depression, panic disorder, other psych condition
diverticulitis
headaches
heart conditions
back problems
high blood pressure
insomnia
muscle strain/sprain
pregnancy
scoliosis
seizures
whiplash
chemical dependency (alcohol, drugs)
If any of the above needs to be detailed or if there is anything else to share, please do so:
Do you have any of the following today:
skin rash
cold/flu
open cuts
severe pain
anything contagious
injuries/bruises
Do you have any allergies to the following:
medications
foods (nuts, etc.)
environmental allergens (dust, pollen, fragrances)
reactions to skin care products
If any of the above are checked, please give details:
What are your goals/expectations for this therapy session?
  

POLICIES OF PROTOCOL FORM

 

I understand that the massage/bodywork 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 further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, or prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand 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 payment of the scheduled appointment.

 

We ask for a 48-hour notice if you are not able to make your scheduled appointment. If you fail to cancel or reschedule your appointment in a timely matter, you will be charged for the full service.

 

I have read, understand and agree to comply with all client policies of protocol for this establishment which are listed above.

Initial here to agree:
Date: