Massage Client Intake Form
PLEASE PRINT LEGIBLY
Name _________________________________________ Email _________________________________ Address ______________________________________ City/State/Zip _________________________ Phone: Home______________Work_______________Cell_______________ Birthday ___/___/___ Occupation ________________________________ Referred to This Office By _________________ In Case of Emergency Please Contact ______________________________Phone______________
General and Medical Information
Y Y Y Y N N N N Have you ever had a professional massage? If yes, how often?
Are you pregnant? If yes, how far along are you? Are you sensitive to touch/pressure in any area? (ticklish?) Are you allergic or sensitive to any oils (essential oils, nut oils, scents)? If yes, please list:
List of current medications and reason:
List of surgeries (type and date):
Indicate Areas of Pain/Tension:
On a scale from 1-10, 10=highest, rate your levels of: Stress __ ____ Pain ___ ___ Energy ___ ___ How did your symptoms begin and when did they start? ________________________________________________________ ________________________________________________________ What have you done for relief? _________________________ Is the condition getting better/worse? __________________
Please check all that apply:
Skin condition-rash, warts, hives, skin cancer, other ___________________ Lymphatic condition-swollen gland, nasal congestion, lymph edema Joint problems/stiffness-arthritis, sacroiliac problems, TMJ, other Bone Condition-osteoporosis, fracture, other ______________ Headaches Recent injury or accident-whiplash, sprain, bruise, other _______________ Circulatory Condition-high blood pressure, varicose veins, blood clots Numbness/Tingling, Sciatica Tendonitis, Bursitis Diabetes
Please mark in the diagram above any areas where you have pain or discomfort.
Massage Client Intake Form Massage Client Waiver Form
Please take a moment to read and initial all of the following statements: If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session. _____ I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness. _____ I affirm that I have notified my therapist of all known medical conditions and injuries. _____ I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapists part should I forget to do so. _____ I understand that massage is entirely therapeutic and non-sexual in nature. _____ By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork. _____ I understand that should I cancel an appointment less than 24 hours before the scheduled time or no show an appointment, I am subject to a fee equal to the cost of the missed appointment. This fee is monetary & cant be taken as an additional punch off a massage package card. If the appointment was booked under a gift certificate, it will be voided in lieu of the fee. _____
Information and Suggestions
Prior to your massage, please remove contact lenses and all jewelry. Pull long hair back with a clip or band. In general, massage is given while you are unclothed. However, you may choose to wear undergarments or a swimsuit. You will be covered with a top sheet throughout your session. This is your massage and you should be as comfortable as possible. Feel free to ask your therapist any questions before, during, or after the session. Your therapist is a highly trained professional and will be happy to make you feel informed and comfortable.
I have received the policy statement, and have read and agree to the policies therein. Client name:____________________________________________________________________ Client signature:_________________________________________________________________ Date:__________________________________________________________________________ Therapist signature:______________________________________________________________
