MASSAGE INTAKE FORM

This information requested below will assist your therapist in providing safe, professional care. This form will be kept in confidence in accordance with HIPAA privacy requirements. Completion of this form is mandated by the Texas Department of State Health Services.

Name

Date of birth

Date

Address

Street Address Line 2

City

Zip

Home

Cell

Emergency contact

Emergency contact Phone

Email

example@example.com

Have you ever experienced a professional massage?

How recently

Do you frequently experience stress with:

Family Work Other

Do you have diabetes?

Do you experience:

Frequent headaches Sinus Migrains

Are you pregnant?

If yes, how many months?

Do you have arthritis?

Are you wearing contact lenses?

Do you have high blood pressure or circulatory problems?

Is it controlled with medication?

Do you use tobacco products?

Do you suffer from epilepsy or seizures?

Is it controlled with medication?

Do you suffer from joint swelling?

Do you have varicose veins?

Have you had any broken bones in the past 2 years?

Do you bruise easily?

Do you have any numbness or stabbing pains?

Do you suffer from back pain?

Sacral Lower Middle Upper

Do you have any contagious diseases?

Do you have allergies?

Topical Oral Environmental

Do you have any other medical conditions about which your therapist should be aware?

What is your primary reason for requesting massage therapy?

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY

Massage is provided for the basic purposes of relaxation and relief of muscular tension. If you have a specific medical condition or specific symptoms, massage therapy may be contraindicated. Massage therapy is not a substitute for medical treatment. Massage therapists do not diagnose illness or prescribe medications. Nothing said in the course of your massage session should be construed as such. Massage therapists do not perform spinal manipulations or skeletal adjustments, nor do they treat any physical or mental illness or disease.

Breast massage after augmentation, reduction or mastectomy has been shown to minimize scar tissue. Breast massage will not be performed unless

these conditions exist and then, only with written consent. Breast massage requires temporary undraping of the breast area to visually inspect the tissue. If you agree to breast massage, please sign your consent below:

Signature for consent for breast massage

Clear

I affirm that I have provided all information requested honestly and fully. If my reason for seeking massage, my medical history or any other consent I have provided changes, I will advise the therapist so that an updated consultation can be completed. I understand that the use of drugs and/or alcohol is contraindicated for massage therapy and I attest that I am not under the influence of drugs and/or alcohol now, nor will I ever be, for a massage session. I hereby give my consent to receive massage therapy today and in the future until I advise otherwise in writing. I also provide my consent to receive massage from other therapists at Chrysalis as noted on this form.

Client's signature

Clear

Date

The following information is provided pursuant to the Texas Department of State Health Services Massage Therapy Rules (25 Texas Administrative Code, Chapter 141 There should be no blank spaces on this form. If not applicable, enter "N/A" in the space provided.

Client's occupation

1. If other than full body massage is planned, list the parts of the client's body that will be massaged

List any areas to be avoided during the massage (i.e. ingrown toenail, a fresh cut, bruise, abrasion, etc.)

3. If other than Swedish massage is planned, list all types of massage initially planned during the session

If you experience any pain or discomfort during the session, you should immediately inform the therapist so that the pressure and/or strokes may be adjusted to your comfort level. If you desire, the session can be modified or terminated at any time.

This massage practice requires that your body be covered (draped) at all times during the session, except for the area/s being massaged. Please do not remove the draping without the therapist's agreement. Any illicit or sexually suggestive remarks or advances made by the client, including removal of draping, will result in immediate termination of the session with the client owing for the entire session.

Massage should not be performed when certain medical conditions exist. Please be sure that you have stated all of your known physical and medical conditions, including medications you currently take and that all of your answers are complete and correct.

The following therapists, at the client's request, have reviewed this information and have been approved by the client to perform massage:

Therapist's signature

Clear

Date

Should you have a complaint about the services of a Licensed Massage Therapist, please contact the Texas Department of State Health Services Massage Therapy Licensing Program at 512-834-6616.

Chrysalis 2615 Southwest Freeway, Suite 240 Houston, TX 77098 713-522-2111 spachrysalis.com