Massage Therapy Intake Form

Have you had a professional massage before?
Do you have difficulty lying on your front, back, or side?
Do you have any allergies to oils, lotions, or aromas?
Do you have sensitive skin?
Are you wearing contacts?
Do you sit for long hours at a time at a workstation, desk, or driving?
Do you perform any repetitive movement in your work, sports or hobby?
Do you experience stress in your work, family, or other aspect of your life?
If yes, how do you think it has affected your health?
Do you have any particular goals in mind for this massage?

Medical History

In order to plan a massage session that is safe and effective, we need some general information about your medical history.
Do you see a chiropractor?
Please check any that apply to you
Draping will be used during the session, only the area being worked on will be uncovered.

Clients under the age of 18 will need to have a parent or guardian present in the spa room unless a waiver has been
signed by guardian.

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscle tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, or medical specialist for any aliment that 1 am aware of. I understand massage therapists are not qualified to preform spinal or skeletal adjustments, diagnose, prescribe, or treat any illness. 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 therapist updated as to any changes in my medical profile and understand there shall be no liability on the therapist part should I fail to do so.
Please use your mouse (or finger if on phone/tablet) to sign your name above.
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Questions about how AL!VE can help you reach your goals? Get in touch.