Massage Intake Form Need some help with your form? Contact Me Client Contact InformationClient Name *Date of Birth *Gender *Address *Phone *Email *Referred ByEmergency Contact *Phone *Physician/ Health-care Provider name *Phone *Is this massage/ bodywork medically necessary (is it for a medical condition, injury, surgery)?YesNoDo you have a physician referral/prescription? *YesNoMassage InformationHave you ever received professional massage/bodywork before?YesNoHow recently?What types of massage/bodywork do you prefer?What kind of pressure do you prefer?LightMediumFirmWhat are your goals/expected outcomes for receiving massage/bodywork?How do you feel today?List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.)Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, childcare)?YesNoExplainList the medications you currently takeAre you wearing contacts?YesNoAre you wearing dentures?YesNoAre you wearing a hairpiece?YesNoAre you pregnant?YesNoHealth HistoryHave you had any injuries or surgeries in the past that may influence today’s treatment?Circle any of the following health conditions that you currently have (If you are unsure, please ask)Blood ClotsInfectionsCongestive heart failureContagious diseasesPitted edemaPlease answer honestly, as massage may not be indicated for the above conditionsPlease indicate conditions that you have or have had in the past. Explain in detail, including treatment received:Past ConditionsPlease indicate conditions that you've had in the past below then explain in the section belowMuscle or joint painMuscle or joint stiffnessNumbness or tinglingSwellingBruise easilySensitive to touch/pressureStroke, heart attackHigh/Low blood pressureVaricose veinsShortness of breath, asthmaCancerNeurological (e.g., MS, Parkinson’s, chronic pain)Epilepsy, seizuresHeadaches, MigrainesDizziness, ringing in the earsDigestive conditions (e.g., Crohn’s, IBS)Gas, bloating, constipationKidney disease, infectionArthritis (rheumatoid, osteoarthritis)Osteoporosis, degenerative spine/diskScoliosisBroken bonesAllergiesDiabetesEndocrine/thyroid conditionsDepression, anxietyMemory Loss, confusion, easily overwhelmedFor any checked above, please explain in detail, including treatment receivedCurrent ConditionsPlease indicate conditions that you have currently below then explain in the section belowMuscle or joint painMuscle or joint stiffnessNumbness or tinglingSwellingBruise easilySensitive to touch/pressureStroke, heart attackHigh/Low blood pressureVaricose veinsShortness of breath, asthmaCancerNeurological (e.g., MS, Parkinson’s, chronic pain)Epilepsy, seizuresHeadaches, MigrainesDizziness, ringing in the earsDigestive conditions (e.g., Crohn’s, IBS)Gas, bloating, constipationKidney disease, infectionArthritis (rheumatoid, osteoarthritis)Osteoporosis, degenerative spine/diskScoliosisBroken bonesAllergiesDiabetesEndocrine/thyroid conditionsDepression, anxietyMemory Loss, confusion, easily overwhelmedFor any checked above, please explain in detail, including treatment receivedConsent for TreatmentConsent *If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners 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 should be construed as such. Because massage/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should 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 the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care. I agree to the terms and conditions stated above.Please Type Name *By typing my name above, I acknowledge that it is equivalent to providing my signature and that I agree to the terms and conditions outlined in this document.Submit Form Need some help with your form? Contact Me
