MASSAGE THERAPY INTAKE FORM
Confidential initial intake form

Jody Wallace, LMT, Energy Medicine Practitioner.       N.Y. state License # 009721-01


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Full Name *
Birth date:
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Email *
Address *
Phone number *
Occupation:
Primary health care provider, (MD):
Did someone refer you?
Stress reduction, exercise, hobbies
Please check what areas of body you give permission to receive massage
What goals or results do you want from your massage sessions?
Health concerns: *
Spinal issues, any injuries, please specify:
Surgeries:
Medications, please list:
HEALTH HISTORY
 Details of items checked above, and/or other health concerns that are not listed above?
 It is my choice to receive massage therapy and body work, I realize the treatment is being given for the well being of my body and mind. This includes stress reduction, relief from muscular tension, spasm or pain, or for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my well being is being compromised.I understand that massage practitioners do not diagnose illness, disease or any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations, I acknowledge that massage is not a substitute for medical examination or diagnosis, and that is recommended that I see a primary health care provider for that service.
Today's date:
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