Massage Intake Form

Please use the form below to help us expedite your first visit to our office.

Tell Us About You

Your First and Last Name:

Street Address:

City:

State:

Zip:

Home Area Code & Phone:

Cell Area Code & Phone:

Work Area Code & Phone:

E-mail Address:

Confirm E-mail Address:

Date of Birth:

Interest(s):

Occupation:

What is your main concern/goal for first session?

Is there any area you would like extra time spent, any area where you seem to hold a lot of tension?

Any area you would like skipped:

What is your previous experience with professional massage/other bodywork?

List any aspects of your life that are particularly stressful (job, posture, habits, diet, family, etc.):

Are you taking any medications?
If so, what and what for?

Medical History

Give brief explanation & dates

Hypertension:

Now Past None

Heart Disease:

Now Past None

Surgeries/Fractures:

Now Past None

Implants of any kind:

Now Past None

Arteriosclersis:

Now Past None

Varicose veins:

Now Past None

Phlebitis:

Now Past None

Fluid retention:

Now Past None

Epilepsy:

Now Past None

Headaches:

Now Past None

Cancer/Malignancy:

Now Past None

Diabetes:

Now Past None

Fractures:

Now Past None

PMS/Painful Menstruation:

Now Past None

Easy bruising:

Now Past None

Skin rash:

Now Past None

Abscess or open sore:

Now Past None

Skin sensitivity:

Now Past None

Allergies:

Now Past None

Herpes I or II:

Now Past None

HIV positive:

Now Past None

Other infectious diseases:

Now Past None

Pregnancy:

Now Past None

Intra Uterine Device:

Now Past None

Mental Illness:

Now Past None

Osteoporosis:

Now Past None

Osteoarthritis:

Now Past None

Rheumatoid Arthritis:

Now Past None

Fibrositis:

Now Past None

Fibromyalgia:

Now Past None

Chronic Fatigue Syndrome:

Now Past None

Herniated Disc:

Now Past None

Inner Ear Problem:

Now Past None

Do you wear contacts?

Yes No

Do you wear dentures?

Yes No

Do you wear hearing aid?

Yes No

Other:

Contract for Care


	I understand that the massage I receive is provided for the basic purpose of relaxation and the relief of muscular tension. If I experience any pain or discomfort during the session, I will immediately inform the practitioner so that pressure/stroke may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical or chiropractic examination, diagnosis or treatment. Because massage should not be performed under certain medical conditions, I affirm that I have stated all of my known conditions and answered all questions honestly. I agree to keep the massage therapist updated as to any changes in my medical/health status. I assume all legal responsibility for my health and well being. I release the massage therapist from any and all present and future responsibility. I understand that the massage therapist reserves the right to terminate my session and further sessions if deemed necessary. I also understand that a missed or canceled appointment may incur charges that I must pay.
	Client Signature: Date:

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