Information Request Form

Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

example@example.com

Phone Number

Area CodePhone Number

Emergency Contact

Phone Number

Please enter a valid phone number.

The following information will be used to help plan safe and effective massage sessions. Please answer the questions to the best of your knowledge.

Date of initial visit

Date

Have you had a professional massage before?

YesNo

If yes, how often do you receive massage therapy?

Do you have any difficulty lying on your front, back, or side?

YesNo

Do you have any allergies to oils, lotions, or ointments?

YesNo

If yes, please explain.

Do you have sensitive skin?

YesNo

Are you wearing

contact lensesdentureshearing aid

Do you sit for long hours at a workstation, computer or driving?

YesNo

If yes, please describe.

Do you perform any repetitive movement in your work, sports, or hobby?

YesNo

If yes, please describe

Do you experience stress in your work, family, or other aspect of your life?

YesNo

If yes, please describe

Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort?

YesNo

If yes, please describe.

Do you have any particular goal in mind for this massage?

YesNo

If yes, please explain.

Are you currently under medical supervision

YesNo

If yes, please explain.

Are you taking any medications?

YesNo

If yes, please list.

Please check any condition that applies to you.

If yes, how many months

Please explain any condition that you have marked above.

Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?

Draping will be used during the session - only the area being worked on will be uncovered. clients under the age of 17 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.

I consent to having the following areas massaged.

I consent to the following modalities should we decide to use them and understand cupping, gua sha and IASTM can leave red marks for a few days.

cuppinginstrument assisted soft tissue mobilization (IASTM)Gua Shaheated Himalayan salt stones or basalt rocks

I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so.

Type your name to agree.

Signature

Date

Studio Panacea Client Intake Form

Medical History- In order to plan a massage session that is safe and effective, I need some general information about your medical history.