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Massage Therapy Intake Form
Name
Phone Number
Email
Have you had a professional massage before?
Yes
No
If yes, how often do you receive professional massages?
Do you have difficulty lying on your front, back, or side?
Yes
No
If yes, please explain
Do you have any allergies to oils, lotions, or aromas?
Yes
No
If yes, please explain
Do you have sensitive skin?
Yes
No
Are you wearing contacts?
Yes
No
Do you sit for long hours at a time at a workstation, desk, or driving?
Yes
No
If yes, please explain
Do you perform any repetitive movement in your work, sports or hobby?
Yes
No
If yes, please explain
Do you experience stress in your work, family, or other aspect of your life?
Yes
No
If yes, how do you think it has affected your health?
Muscle tension
Anxiety
Insomnia
Irritability
Other…
Enter other…
Is there any particular area of the body where you are experiencing tension?
Do you have any particular goals in mind for this massage?
Yes
No
If yes, please explain
Please list any areas of the body you want the massage therapist to focus on
Medical History
In order to plan a massage session that is safe and effective, we need some general information about your medical history.
Are you under the care of a medical professional? If yes, please explain
Do you see a chiropractor?
Yes
No
If yes, how often?
Are you currently taking any medications? Please list
Please check any that apply to you
Contagious skin condition
Blood clots
Recent accident or injury
Artificial joint
Current fever
Allergies/sensitivities
TMJ
Recent surgery
Fibromyalgia
Circulatory disorder
Phlebitis
Easy bruising
Osteoporosis
Cancer
Decreased sensation
Heart condition
Epilepsy
Sprains or strains
Varicose veins
Open sores or wounds
Arthritis, tendinitis, joint disorder
Recent fracture
Diabetes
Swollen glands
High/low blood pressure
Headaches/migraines
Back/neck problems
Carpel tunnel syndrome
Please explain any condition you have marked above
Are you currently pregnant? If so, how many months
Is there anything else about your health history that you think would be useful for your massage therapist to know?
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 input your full name to agree to the statements above.
Signature
Please use your mouse (or finger if on phone/tablet) to sign your name above.
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