Massage Intake Form
ABOUT YOU
Full Name
Date of Birth
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HEALTH INFORMATION
Please mark all areas of concern:
Have you had a massage before?
Yes
No
Preferred Pressure?
Light
Moderate
Deep
Are you pregnant?
Yes
No
Do you bruise easily?
Yes
No
Do you frequently suffer from stress?
Yes
No
Do you have diabetes?
Yes
No
Do you suffer from arthritis?
Yes
No
Are you wearing contact lenses?
Yes
No
Are you wearing dentures?
Yes
No
Do you have high blood pressure?
Yes
No
Do you suffer from epilepsy or seizures?
Yes
No
Do you suffer from joint swelling?
Yes
No
Do you have varicose veins?
Yes
No
Do you have any contagious diseases?
Yes
No
Do you have any allergies?
Yes
No
Do you have osteoporosis?
Yes
No
Have you had any broken bones in the past two years?
Yes
No
Do you have any cardiac or circulatory problems?
Yes
No
Do you have numbness, tingling or sharp pains anywhere?
Yes
No
Are you very sensitive to touch or pressure in any area?
Yes
No
Have you ever had surgery?
Yes
No
Please specify any previous surgeries:
Do you have any tension or soreness in a specific area?
Yes
No
Please specify any areas of tension or soreness:
Do you have any other medical conditions or are you taking any medications I should know about?
Yes
No
Do you experience frequent headaches?
Yes
No
Do you suffer from neck or back pain?
Yes
No
Have you been in a collision or suffered any injuries in the past two years?
Yes
No
Please specify any previous collisions or injuries:
Is there any additional information you would like us to know?
Person responsible for this account if other than the patient:
For my balance my preferred method of payment is:
Cash
Check
Credit Card
I understand that the massage/bodywork I receive is provided for relaxation and relief of muscular tension.
I will immediately inform the practitioner If I experience any pain or discomfort, so that the pressure and/or strokes may be adjusted.
I understand that the massage/bodywork should not be construed as a substitute for medical diagnosis or treatment.
I affirm that I have stated all my known medical conditions.
I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part if I fail to do so.
I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of this session.
I authorize the doctor or his staff to render care as deemed appropriate for me and/or my child.
Signature
Date
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Month
-
Day
Year
Date
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