Tucson Mindful Massage Intake Form

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Thank you for taking the time to complete this form so I can provide the best possible experience for you.

Email *

Name *

Phone *

Home Address *

Referred By: *

Occupation *

Have you ever experienced a professional massage or bodywork session? *

Yes

What are your massage/bodywork goals? *

What kind of pressure do you prefer? *

Light

Medium

Firm

Do you have any of the following conditions? *

Yes

Diabetes

Arthritis

High blood pressure

Epilepsy or seizures

Joint swelling

Varicose veins

Osteoporosis

Allergies

Cardiac or circulatory problems

Any contagious disease

Do you experience any of the following? *

Yes

Frequent headaches

Bruise easily

Broken bones or injuries in last 2 years

Numbness or stabbing pains

Are you pregnant? *

Yes

Do you have any history of surgeries, medical conditions or medications that I should be aware of? *

I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular 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 massage or 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 for which I am aware. I understand that massage 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 given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all of 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 should 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 will result in termination of the session. *

I agree.

I disagree.

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