Massage Form
Massage Intake Form
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Email *
Today's Date: *
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First Name, Last name *
Address *
Date of Birth *
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Telephone Number *
In Case of Emergency, please contact *
Emergency Contact Phone Number *
Occupation *
Age *
Gender *
Physician's Name *
Please take a moment to carefully read the following information, and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
If you answer yes to any of the following questions, please explain as clearly as possibly.
Have you experienced a professional massage/bodywork session? *
How recently? *
Do you frequently suffer from stress? *
Do you have diabetes? *
Do you experience frequent headaches? *
Are you pregnant? *
Do you suffer from arthritis? *
Are you wearing contact lenses? *
Are you wearing dentures? *
Do you have high blood pressure? *
If yes, for the previous questions, are you taking medication for this? Please answer yes or no, and if yes, list medications below. *
Do you suffer from joint swelling? *
Do you suffer from epilepsy or seizures? *
Do you have varicose veins? *
Do you have any contagious diseases? *
Do you have any allergies? *
If so, please list: *
Do you bruise easily? *
Have you had any broken bones in the past 2 years? *
Do you have osteoporosis? *
Have you been in an accident or suffered an injury in the past 2 years? *
Do you have tension or soreness in a specific area? *
If yes, please specify: *
Do you have cardiac or circulatory problems? *
Do you suffer from back pain? *
Do you have numbness or stabbing pains anywhere? *
Are you very sensitive to touch or pressure anywhere? *
Do you have any other medical conditions or are you taking any medications? *
Comments:
I understand that the massage/bodywork I receive I provided for the basic purpose of relaxation and relief of tension. 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 the massage/bodywork should construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialists 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, diagnoses, prescribe, or treat any physical or mental illness, and nothing said in the course of the session given 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 there shall be no liability on the practitioner's or salon'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. *
Consent of Treatment of Minor: By selecting YES below, I hereby authorize the massage therapist employed by Emidio Vincenzo ESCAPE to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
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