Massage Intake Form

Name: ______DOB: ___/___/_____

Address: ______

City: ______State: ______Zip Code: ______

Phone Number: ______

Email Address: ______

Occupation: ______

Have you ever received massage therapy before? ___ Yes ___No

If yes, what type of massage therapy? ______

Are you currently taking any medications? ___ Yes ___ No

If yes, please list the medications you are taking and the reason why: ______

______

______

Are you currently seeing a healthcare professional? ___ Yes ___ No

If yes, please list the names and reason for treatment: ______

______

______

Please review the following list and mark the conditions that you have a history of either recently or in the past.

Arthritis / Auto-Immune Condition
Depression / Muscle Strain/Sprain
Diabetes / Hepatitis(A, B, C, other)
Diverticulitis / Pregnancy
Broken or Dislocated Bones / Skin Conditions
Headaches / Scoliosis
Bruise Easily / Stroke
Heart Condition / Seizures
Cancer / Surgery
Back Problems / Whiplash
Chronic Pain / TMJ Disorder
High Blood Pressure / Chemical Dependency
Constipation / Other:
Insomnia

Do you have any of the following presently:

___ Skin Rash ___ Cold / Flu ___ Open Cuts ___ Severe Pain ___ Anything Contagious __Injuries/Bruises

Do you have any allergies to:

__ Medications ___ Foods ___ Environmental Allergens ___ Reactions to Skin Care Products

If any of the above are checked please provide details: ______

______

______

Are you wearing: ___ Contact Lenses ___ Hearing Aid ___ Hairpiece

What are your goals / expectations for this therapy session? ______

______

______

1.  I understand that massage therapy can be very therapeutic, relaxing and reduce muscle tension, it is not a substitute for medical examination, diagnosis and treatment by a physician.

2.  This is strictly a therapeutic massage and any remarks or advances that are sexual in nature will terminate the session and I will be held liable for the payment of the scheduled treatment.

3.  Massage should not be done under certain medical conditions, I hereby affirm that I have answered all of the above questions that pertain to my medical condition truthfully.

Signature: ______Date: ___/___/_____