Massage Intake Form

Wellspring Health Center|Massage Client Information

Date

Name

First NameLast Name

Age

Birthdate

Date

Address

Street Address Line 2

City

Zip

Email

example@example.com

Primary Phone#

Format: (000) 000-0000.

Occupation

Are you pregnant?

Due Date

Date

How did you hear about Wellspring?

Health Insurance Plans

Please circle the areas you would like the massage therapist to focus on:

What are your chief complaints

When did these symptoms start

What treatment have you had for these symptoms?

Is this the result of an accident or injury?

Accident or injury date:

Date

Describe accident or injury:

Current Health Conditions

Current Medications

Known Allergies

Any allergies to lotions, oils, or essential oils?

Describe lotion/oil/essential oil allergies:

Do you have any pain or mobility issues that make it hard to do any of the following activities?

What are your top 1 - 2 goals for receiving massage therapy?

Would you like information about any of these Wellspring services?

A. I understand that the massage given to me by a certified massage therapist at Wellspring Health Center is for stress reduction, pain reduction, relief from muscle tension, or increasing circulation.

B. I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, non are spinal manipulations part of massage therapy.

C. I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have.

D. I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any.

E. I acknowledge that I have been informed of Wellspring Health Center’s cancellation and no-show policies and agree to abide by them. The full policies are available at https://wellspring-hc.com/massage-appointment-policy/

Signature

Date