Massage Therapy Client Intake Form

First Name
Last Name
Date of birth

MonthDayYear
Date
Address
City
State
Zip Code
Emergency contact & Phone Number
Physician's Name
Physician's Phone
How would you rate your general health?

ExcellentYes (Date of last treatment)Have you had a professional massage before?FairPoorNo
List current medications & the conditions they are treating
List any major accidents or surgeries (including dates)
Do you have any allergies or hypersensitivities
What is the primary purpose of your visit? (relaxation, treating an injury, reduce stress?)
What type of pressure do you prefer?

LightMediumDeep Tissue
List any areas of the body you'd like excluded from massage (Example: Feet, Face, Head/Hair)
List any special needs or requests (example: lighter pressure on a certain body part, help getting on/off table ext)
RESPIRATORY

AsthmaShortness of breathChronic coughBronchitisEmphysemaSinusitisFrequent coldsSmokerFamily history of respiratory difficulties
HEAD & NECK

Headaches/migrainesVertigo / dizzinessRinging in earsHearing lossVision problemsVision loss
CARDIOVASCULAR

High blood pressureLow blood pressureHeart attack StrokeHeart diseasePoor circulationPhlebitis / varicose veinsPacemakerHemophiliaChronic congestive heart failureFamily history of cardiovascular problems
SKIN & INFECTIONS

HepatitisHIV/AIDSHerpesTuberculosisLyme diseaseInfectious skin conditions
NERVOUS SYSTEM

Sensory loss/changeNumbness/tinglingEpilepsySeziureSciaticaMultiple sclerosis
MUSCULOSKELETAL SYSTEM

CancerDiabetesUnexplained weight lossDigestive conditionsFamily history of arthritisArthritisFibromyalgiaChronic fatigue syndromeOsteoporosisTendonitisDepressionAnxietyJaw pain (TMJ)BursitisPsychiatric disorderPins / plates / wires / artificial jointOther conditions
REPRODUCTIVE

PregnantGiven birthGynecological problems
OTHER CONDITIONS

CancerUnexplained weight lossFibromyalgiaDepressionPsychiatric disorderDiabetesDigestive conditionsChronic fatigue syndromeAnxiety
PLEASE EXPLAIN OTHER CONDITIONS NOT LISTED
I am aware of the benefits and risks of massage.

I understand that there is no implied or stated guarantee of the effectiveness of the services I recieve.

I understand that New York State Massage Therapists are licensed health professionals who apply a variety of scientifically developed massage techniques to the soft tissue of the body to improve muscle tone and circulation.

Massage therapists work to enhance well-being, reduce the physical and mental effects of stress and tension, prevent disease, and restore health.

I acknowledge that massage therapy is not a substitute for any medical care provided by a physician. I consent to any necessary communications between my physician and massage therapist about my personal health information, relavent to any massage service I recieve. I agree to use massage therapy in conjunction with the care I recieve from a physician.

I agree to disclose any advisement or recommendation from my physician against the use of massage therapy to my massage therapist prior to recieving services.

I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I consent to the collection of my personal information provided in this form.

I understand that the information provided will be kept confidential unless otherwise required by law.

Massage Therapy treatments may be covered by extended health care plans. I understand that my massage therapist isn't responsible for any transaction or communication between my insurance provider and myself in regard to any balance due. My massage therapist may accept certain health cards to process the balance due, but there is no guarentee that the transaction will be successful.

I agree that I am personally responsible for the entire balance due at the time of service.

By signing this form, I affirm that I've agreed to the above statements and that the information I've provided in this form is accurate and true to the best of my knowledge. I understand and consent to the electronic transmission of this form.
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