Massage Therapy Form
An accurate health history ensures that it is safe for you to receive a massage treatment, and helps the therapist determine a proper treatment plan. When your health status changes in the future, please let us know. All information in this form is confidential and your written authorization is legally required to release it.
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height
Weight
Primary care doctor
Doctors Phone Number
-
Area Code
Phone Number
May we contact
YES
NO
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Health Data
Have you ever had a massage before? For relaxation or other reasons?
Current medications?
If yes, please specify on the field above.
Previous major illnesses and/or operations?
If yes, please specify on the field above.
Have you ever been in an accident? If so, when?
(Female only) Are you pregnant or nursing?
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Please indicate all conditions you have experienced: Joint/Soft Tissue Discomfort
Arms
Upper Back
Mid Back
Lower Back
Degenerative Discs
Feet
Hands
Shoulders
Hips
Jaw
Knees
Legs
Neck
Osteo Arthritis
Rheumatoid Arthritis
Sciatica Limitation of Movement
Other
Please indicate all conditions you have experienced: Skin
Rashes
Itching
Bruise Easily
Dryness
Boils
Athlete's Foot
Warts
Other
Please indicate all conditions you have experienced: General Symptoms
Fainting
Dizziness
Loss of sleep
Fatigue
Nervousness
Sudden Weight Loss/Gain
Numbness
Tingling
Paralysis
Headaches (Tension)
Migraines
Other
Location of painful areas
COVID-19 Screening Questionnaire
If you answer yes to any of the following please do not come in for massage treatment.
In the past 14 days have you had direct contact with someone that has tested positive, or who is suspected for having COVID-19?
Do you have signs or symptoms of a respiratory infection such as fever, cough, or sore throat?
Have you been told to quarantine by the public health department?
How did you hear about our office?
Consent and Waiver
Type a question
I authorize the use of lotion, oil, and ointments to my body.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release this massage center for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: