Massage Intake Form

Massage Intake Form

(Serendiptity Salt & Skin Spa, LLC / DBA SERENDIPITY MASSAGE & SKIN SPA)
First Name
Last Name
Referred by
Email Address (for receipts and/or marketing)
example@example.com
Date of birth

MonthDayYear
Date
Contact Phone #
Have you had a professional massage before?

YesNo
CURRENT MEDICATIONS (OPTIONAL) PLEASE LIST IF ON PAIN MEDS / BLOOD THINNERS OR MEDICATIONS THAT MAY EFFECT OUR SERVICE
Please tell us about any allergies or hypersensitivities - EX: LOTIONS / FRAGRANCES, ETC
Have you had any major surgeries or accidents? Please list below:
RESPIRATORY

AsthmaShortness of breathChronic coughBronchitisEmphysemaSinusitisFrequent coldsSmokerFamily history of respiratory difficultiesOther
Head Neck - Cardiovascular

Headaches / migrainesVertigo / dizzinessHigh blood pressureLow blood pressureRinging in earsHearing lossHeart attackStrokeVision problemsVision lossHeart diseasePoor circulationPhlebitis / varicose veinsPacemakerHemophiliaChronic congestive heart failureFamily history of cardiovascular problemsOther
SKIN & INFECTIONS

HepatitisHIV / AIDSHerpesTuberculosisLyme diseaseInfectious skin conditionsOther
NERVOUS SYSTEM

Sensory loss / changeNumbness / tinglingSciaticaEpilepsySeizuresMultiple sclerosisOther
OTHER CONDITIONS

CancerDiabetesUnexplained weight lossDigestive conditionsArthritisFamily history of arthritisFibromyalgiaChronic fatigue syndromeOsteoporosisTendonitisDepressionAnxietyBursitisJaw pain (TMJ)Psychiatric disorderPins / plates / wires / artificial jointOther conditions
REPRODUCTIVE

PregnantGiven birthGynecological problems
It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.
Signature:*

Clear
Date:

MonthDayYear
Date
Should be Empty: