Intake Form
Intake form
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Email *
Name *
Address *
Phone number *
Date of Birth *
MM
/
DD
/
YYYY
Occupation *
Emergency contact *
The following information will be used to help plan a safe and effective massage session. Please answer the questions honestly.
Have you had a professional massage before? *
Yes
No
Answer
If yes, please give details.
Do you have any difficulty lying on your front, back, or side? *
Yes
No
Answer
Do you have any allergies to oils, lotions, or ointments? *
Yes
No
Answer
If yes, please give details.
Do you have sensitive skin? *
Yes
No
Answer
Are you wearing? *
Yes
No
Hearing aid
Prosthetic
Contact lenses
Dentures
Do you sit for long hours at a workstation, computer, or driving? *
Yes
No
Answer
 Do you perform any repetitive movement in your work, sports, or hobby? *
Yes
No
Answer
Do you experience stress in your work, family, or other aspect of your life? *
Yes
No
Answer
If yes, how do you think it has affected your health?
Yes
No
Irritability
Insomnia
Muscle tension
Anxiety
Clear selection
If there are particular areas of discomfort please give details.
Do you have any particular goals in mind for this massage session?
General Medical History
If you are currently under medical supervision including medication please explain
Please check any condition listed below that applies to you:
Yes
Contagious skin condition
Phlebitis
Open sores or wounds
Deep Vein Thrombosis/ Blood Clot
Easy Bruising
Joint/ Bone disorder
Recent Fracture
Epilepsy
Recent Surgery
Headaches/Migraines
Artificial Joint
Cancer
Sprains/Strains
Diabetes
Current Fever
Decreased Sensation
Swollen Glands
Back/Neck problems
Allergies/Sensitivity
Fibromyalgia
High/ Low Blood Pressure
Circulatory Disorder
Varicose Veins
Pregnancy
Atherosclerosis
Please explain any condition that you have marked above
Is there anything else about your health history that you think would be useful for your massage practitioner to know to plan a safe and effective massage session for you?
Draping will be used during the session – only the area being worked on will be uncovered. Clients under the age of 17 or vulnerable adults must be accompanied by a parent or legal guardian during the entire session. *vulnerable adult, or adult at risk, is a person over the age of 18 who is unable to take care of themselves, or unable to protect themselves against significant harm or exploitation and/ or having a mental illness that impacts their decision making.
By submitting this form I understand that the massage I consent to either for myself, or on behalf of a minor, or vulnerable adult, is provided for the purpose of relaxation and relief of muscular tension. If I/they experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my/their level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I/they should see a physician, or other qualified medical specialist for any mental or physical ailment that I am aware of.
I have read and understood the policies *
Required
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